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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001436
Report Date: 10/22/2024
Date Signed: 10/23/2024 01:47:57 PM

Document Has Been Signed on 10/23/2024 01:47 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PINE VILLE CARE HOMEFACILITY NUMBER:
045001436
ADMINISTRATOR/
DIRECTOR:		SERRANO,NORA CHAVEZFACILITY TYPE:
735
ADDRESS:1681 PINE STREETTELEPHONE:
(530) 533-1851
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY: 6CENSUS: 4DATE:
10/22/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Nora Serrano - licenseeTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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10/22/2024 09:30 AM An informal office meeting was held via TEAMS. Attendees included licensee Nora Serrano, Licensing Program Manager (LPM) Lauren Crocker and Licensing Program Analyst (LPA) Rebecca Knight.

The following items were discussed:

Type A & Type B complaints

Steps the licensee has taken to ensure that staff understand they have to call 911 so the client can be assessed for injury after a client has a fall.

Steps the licensee has taken to ensure that staff understand they have to call 911 so the client can be assessed if they complain of pain or discomfort.

In order to to ensure that staff understand they have to call 911 so the client can be assessed for injury after a client has a fall the licensee had a staff meeting and emphasized that staff need to call 911 no matter what If a client complains of pain or discomfort or had a fall. Licensee will ensure at shift change there is a continuation of care to the next shift so staff are aware of the current status of the clients.

LPM suggested that staff should call 911 if the resident has a history of falls.

LPM encouraged licensee too make sure staff are not burned out. To make sure that the staff is a good personality fit to work with the client. To find staff strengths to where it is not going to impact the facility negatively.

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PINE VILLE CARE HOME
FACILITY NUMBER: 045001436
VISIT DATE: 10/22/2024
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LPM would like to see ongoing training of staff regarding in the event of an emergency what staff are supposed to do, how they notify the licensee, and what the licensee’s role is when a client has an injury or change of condition.

Licensee has asked the house manager to update the licensee daily, and the licensee will follow up as needed. Licensee has asked staff to document any incidents in detail.

LPM reminded the licensee that if a client yells with behaviors that staff should ask them if they are in pain. Licensee should update the client’s care plan with any changes or needs regularly.

Licensee stated they have told staff if they are not sure what is going on with a client they are to call the licensee and the house manager immediately.

LPM provided licensee with training materials for staff and reiterated that the department is here to support the licensee and their staff

Powerpoint "Tips for Supporting Social and Emotional Development - Developing a relationship with your resident" was provided to the licensee to use in staff training.

No deficiencies were issued during the meeting.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
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