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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001436
Report Date: 07/23/2024
Date Signed: 07/23/2024 12:55:34 PM

Document Has Been Signed on 07/23/2024 12:55 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:
07/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Blanca Chavez - house managerTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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07/22/2024 12:00 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with house manager Blanca Chavez. LPA contacted licensee Nora Serrano and obtained permission to meet with Ms. Chavez in Ms. Serrano's absence. Today’s visit is regarding an incident that occurred on 04/15/2024 and was reported to licensing the same day.

It was reported that on 04/15/2024 Far Northern Regional Center (FNRC) nurse Camarena performed an unannounced visit. While checking C1's medication log, it was discovered that on April 3 through 5, 2024 C1 had missed three dosages of Clozapine. The missed dosages were due to the medication not being delivered by the pharmacy. Staff contacted the pharmacy and the medication was delivered on April 5, 2024. Staff had signed the medication log as if they administered the dosage on April 5, but after looking at the medication bubble pack and counting the medication it was discovered that the dose for that day was not administered.

During the course of the investigation, it was learned the medication was ordered from the pharmacy a week before it ran out, and they said they would deliver. After two days the house manager called and checked and they kept saying they would deliver the medication. The house manager told staff to let them know a week in advance before a medication runs out. The house manager instructed staff to dispense the medication to C1 as soon as it was delivered by the pharmacy.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Nora Chavez.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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Document Has Been Signed on 07/23/2024 12:55 PM - It Cannot Be Edited


Created By: Rebecca Knight On 07/23/2024 at 11:34 AM
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: PINE VILLE CARE HOME
FACILITY NUMBER: 045001436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2024
Section Cited
CCR
80075(b)

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80075 (b) Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:
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Licensee agrees to conduct a medication training for all staff concerning the requirement to ensure that clients do not run out of their medications and will provide LPA with training subject matter and sign in sheet with dates and staff signatures. In addition, licensee shall submit a plan to LPA that outlines the process that all staff must follow to ensure that clients do not run out of medications.
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Based on interviews and evidence obtained it was determined that C1 was not dispensed one medication for three days. This poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 08/06/2024.

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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:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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