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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002629
Report Date: 04/10/2024
Date Signed: 04/10/2024 03:34:03 PM

Document Has Been Signed on 04/10/2024 03:34 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:STEPPING STONES CCFFACILITY NUMBER:
045002629
ADMINISTRATOR/
DIRECTOR:		KUSSEROW-FRAZIER, ANNETTEFACILITY TYPE:
735
ADDRESS:215 VALLEY VIEW DRTELEPHONE:
(530) 534-4464
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY: 6CENSUS: 4DATE:
04/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Annettte Frazier - licenseeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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04/11/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived unannounced to conduct a case management visit related to deficiencies cited by Far Northern Regional Center (FNRC) on/around 03/29/2024. LPA met with licensee Annette Frazier explained the purpose of the visit.

LPA reviewed the Corrective Action Plan (CAP) provided to the Department by FNRC on 04/04/2024, describing the specific deficiencies found. The deficiencies were observed as follows:

On 12/13/2024 during an inspection by FNRC staff a deficiency was issued because the administrator certificate for the licensee/administrator had expired on 01/31/2019. Licensee reported in 2022 they had completed CEU classes and had submitted documentation and payment for the certificate and re-sent late fee payment in 2023. Documentation was not available for review during FNRC monitoring to confirm. On 09/07/2023 LPA Knight issued a citation for the licensee holding an expired administrator certificate and licensee was provided instruction to obtain the required training, submit for renewal and submit updated certificate as proof of correction. To date this has not been completed by the licensee. On 04/05/2024 LPA Knight was notified by the Administrator Certification Bureau (ACB) that since the administrator certificate expired on 1/31/2019 it is beyond the 4-year window of renewal; therefore, the licensee is ineligible to renew their certificate. Per ACB if the licensee wishes to pursue administrator certification, they must revisit the first step of the process and enroll in an Initial Certification Training Program course. LPA shared this information with the licensee. The allegation that the administrator does not hold a current administrator certificate is substantiated. This is a repeat violation within a 12-month period, an immediate civil penalty of $250.00 is being assessed as a result.

Continued on LIC809-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
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: STEPPING STONES CCF
FACILITY NUMBER: 045002629
VISIT DATE: 04/10/2024
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On 3/29/2024 FNRC staff toured the facility and discovered the following physical plant violations: Client 1's bed was urine soaked and their room smelled strongly of urine. In Client 2’s room, there is a cubby that was leaning heavily to one side next to the bed that is significantly wobbly, unstable, and hazardous. There was a large water spot on the hallway ceiling by the closet and reported that when it rains heavily water comes into that spot. The physical plant allegations are substantiated.

On 3/29/2024 FNRC staff reviewed client MAR’s and found that not all clients had current PRN letters on hand. There was a discrepancy on the MAR and it did not match SG's bubble pack for Lamotrigine medication. Administrator contacted the pharmacy and was told it was a pharmacy error and they will send out the correct dosage. Administrator was instructed to complete a GER for the medication error, to date it has not been completed. Medication error occurred on 3/14/24 and 3/21/24 for client: SG. The Administrator was instructed several times to complete SIRs/GERs in Therap for these medication errors. The allegation of failure to report is substantiated.


Based on evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided.



An exit interview was conducted. Copy of report and appeal rights to be emailed to licensee immediately following the visit.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/10/2024 03:34 PM - It Cannot Be Edited


Created By: Rebecca Knight On 04/10/2024 at 11:14 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: STEPPING STONES CCF
FACILITY NUMBER: 045002629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2024
Section Cited
CCR
85064(b)

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85064(b) Administrator Qualifications and Duties (b) All adult residential facilities shall have a certified administrator. This requirement is not met as evidenced by:
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Licensee agrees to hire an interim administrator who shall remain in place administering the facility until licensee has completed the requirements and has submitted all required documentation to the Administrator Certification Unit (ACU) for renewal of their administrator certificate. Licensee must obtain and submit written proof from the ACU of their acceptance and approval of licensee’s submitted materials. Once licensee has completed these requirements, they can request from the department that the temporary administrator be dismissed but must receive approval from the department before she dismisses the temporary administrator. Finally, licensee shall submit new administrator certificate to LPA Knight once received.
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Based on the evidence that was obtained it was determined that the licensee’s administrator certificate expired in 2019 and the licensee has not renewed their administrator certificate which poses an immediate health and safety risk to residents in care. On 09/07/2023 LPA issued a citation for the licensee holding an expired administrator certificate and licensee was provided instruction to obtain the required training, submit for renewal and submit updated certificate as proof of correction. This was not completed by the licensee. This is a repeat violation within a 12-month period, an immediate civil penalty of $250.00 is being assessed as a result.
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Licensee must hire interim administrator and that administrator must be present and working in the facility by May 8, 2024. If licensee requires additional time she will contact LPA. Licensee shall submit the following documents to LPA by May 8, 2024 as proof of correction: A letter on company letterhead (signed by licensee) that includes the following information about the interim administrator: Name, residence and mailing address of the interim administrator, date he/she assumed or is expected to assume their position, description of his/her background and qualifications including documentation of required education (photocopy acceptable). Updated LIC500 Personnel Report, copy of administrator certificate, Criminal record clearance that is associated to the facility, Copy of California driver’s license.
Type B
05/01/2024
Section Cited
CCR80087(a)

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80087(a) Buildings and Grounds - (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by:
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Licensee agrees to ensure that any time a bed has soiled sheets those sheets are immediately replaced and laundered, remove cubby from Client 2’s room, hire a licensed contractor to inspect and repair the cause of the water spot on ceiling in the hallway. These repairs shall be completed by May 1, 2024. Licensee shall submit invoices and photographs to LPA as proof of correction.
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Based on the evidence that was obtained it was determined that Client 1's bed was urine soaked and their room smelled strongly of urine. In Client 2’s room, there is a cubby that was leaning heavily to one side next to the bed that is significantly wobbly, unstable, and hazardous, there is a large water spot on the hallway ceiling by the closet which poses a potential health and safety risk to residents in care.
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Licensee shall submit invoices and photographs to LPA as proof of correction.
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: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/10/2024 03:34 PM - It Cannot Be Edited


Created By: Rebecca Knight On 04/10/2024 at 11:19 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: STEPPING STONES CCF
FACILITY NUMBER: 045002629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2024
Section Cited
CCR
80061(a)

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80061(a) Reporting Requirements - (a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department. This requirement was not met as evidenced by:
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Licensee agrees to submit required GER reports to FNRC and CCLD. Additionally, licensee agrees to submit a statement of understanding to LPA concerning reporting requirements and the importance of reporting timely. Licensee shall submit all aforementioned documents to LPA by April 24, 2024, as proof of correction.
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Based on the evidence that was obtained it was determined that FNRC instructed the administrator to complete a GER for medication errors that occurred on 3/14/24 and 3/21/24 for 1 client. Do date no GER was submitted by the administrator as required which poses a potential health and safety risk to residents in care.
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Licensee shall submit all aforementioned documents to LPA by April 24, 2024, as proof 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:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
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