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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701274
Report Date: 08/12/2024
Date Signed: 08/12/2024 01:08:24 PM

Document Has Been Signed on 08/12/2024 01:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOOD DAYSFACILITY NUMBER:
032701274
ADMINISTRATOR/
DIRECTOR:		SIX, ZULLYFACILITY TYPE:
735
ADDRESS:13511 BATES RDTELEPHONE:
(209) 296-4699
CITY:SUTTER CREEKSTATE: CAZIP CODE:
95685
CAPACITY: 4CENSUS: 4DATE:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:27 AM
MET WITH:Paul ZullyTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 8/12/24, at 10:27am, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct their required annual inspection visit. LPA met with Paul Zully and explained the purpose of the visit. During this visit, 4 clients in care were out in the community. Facility is currently service 4 ambulatory adult clients.

At 10:45am, LPA and Paul inspected the physical plant of the facility. The facility is a one-story home located in a residential neighborhood. Front yard and backyard were observed to be clean and free of obstruction. LPA observed outdoor furniture for clients use. The facility has an empty pool that is not in use and it is observed to be fenced, at least 5 feet in height, and observed to be locked and inaccessible to clients in care. The deck at the back area was observed to be in good repair at this time.

Four client bedrooms were inspected and observed to be clean and large enough space to accommodate client belongings. Two bathrooms were inspected and observed to be clean and in good repair. LPA observed the trash bins in both bathroom do not have lids. Technical assistance was provided for licensee to obtain trash bins with lids on. The kitchen was inspected and observed to be sanitized and in good repair. Food supplies were stored properly. Facility maintains an adequate amount of food supply with 2-day perishables and 7-day nonperishables. Smoke detectors/carbon monoxide monitor combo were observed and tested and were found to be operable during this visit. Sharps, toxins and medications were observed to be locked and inaccessible to clients. Facility was observed to have adequate supply of linens for clients. Fire extinguisher was observed at the dining area and last serviced on 6/5/24. Room temperature was at 76*F and hot water temperature was at 110*F in both bathrooms. Facility does not have fireplace.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/12/2024 01:08 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 08/12/2024 at 12:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOOD DAYS
FACILITY NUMBER: 032701274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [record review, the licensee did not comply with the section cited above. During medication review of R1's medication, it was observed R1 was not receiving medications as prescribed according to the dosage amount in one of their prescribed medications which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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License to submit a statement of understading regarding the regulation noted above. Statement to be submitted by POC due date.
Discussion with staff (Paul Zully) for licensee to either change the prescription or obtain the medication with the right dosage.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOOD DAYS
FACILITY NUMBER: 032701274
VISIT DATE: 08/12/2024
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LPA reviewed 4 of 4 client records and technical assistance was provided to Licensee to PRN Authorization for 1 of 4 clients. It was observed through record review that 1 of 4 client (R2) did not have their PRN Authorization Letter completed and signed by their physician. LPA review and counted with Licensee 4 of 4 residents' P&I money and found to be accurate. LPA reviewed 2 of 4 clients medications. LPA observed 1 of 2 client (R1) medication has a prescribed medication dosage of 1000IU and facility has 2000IU of the same medication in hand. LPA reviewed 4 personnel records and records were found to be in compliance at this time with current 1st Aid/CPR certificates and background clearance. Facility conducts monthly emergency drills with last drill was conducted on 7/14/24.

LPA requested copies of the following documents to be emailed: current Liability Insurance Certificate, Surety Bond, LIC500, LIC308 and LIC610D.

Based on today's inspection, per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed or cited.
Exit interview held with Paul Zully, and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC809 (FAS) - (06/04)
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