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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002763
Report Date: 06/25/2024
Date Signed: 06/25/2024 01:52:16 PM

Document Has Been Signed on 06/25/2024 01:52 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:MAINS'L - MONTEREYFACILITY NUMBER:
045002763
ADMINISTRATOR/
DIRECTOR:		DUGAN, COURTNEYFACILITY TYPE:
735
ADDRESS:278 PANAMA AVETELEPHONE:
(530) 899-1907
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY: 5CENSUS: 3DATE:
06/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:04 AM
MET WITH:Administrator- Brandy WilsonTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 06/25/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Brandy Wilson and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, shed, and common restrooms. LPA observed two of the three bed rooms had the required lighting as one of the three bedroom was missing a working light or lamp. LPA observed the each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster.

LPA observed the medications to be unlocked and accessible to residents. LPA observed two locations within the home, the kitchen and laundry area in which the locks for the chemicals were not in working order leaving chemicals accessible to residents.

Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 108 F. LPA observed two (2) fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed the emergency disaster to be complete with the required emergency disaster drills. LPA observed a complete emergency first aid kit ready for emergency use.

LPA reviewed a total of three (3) residents' files and was unable to review staff files. LPA observed two of the three files reviewed to be missing the TB testing and results. The administrator was reviewing and updating the files, the LPA was unable to review staff files at the time of the inspection.


Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.
Several topics were discussed. An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 06/25/2024 01:52 PM - It Cannot Be Edited


Created By: Jaynae Boyles On 06/25/2024 at 01:21 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: MAINS'L - MONTEREY
FACILITY NUMBER: 045002763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that chemicals were found to be accessible to residents, the locks used to make them inaccessible were not in working order at the time of the inspection, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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The administrator will ensure that all chemicals are locked and inaccessible to residents. The administrator will train the staff of the importance of storing chemicals inaccessible to residents, and inform the LPA of the training.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the medications lockes were not in working in order leaving medications accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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The Administrator will ensure that medications are stored inaccessible to residents by replacing the storage for medications with the abiity to lock the medications.
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:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/25/2024 01:52 PM - It Cannot Be Edited


Created By: Jaynae Boyles On 06/25/2024 at 01:21 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: MAINS'L - MONTEREY
FACILITY NUMBER: 045002763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(d)
Fixtures, Furniture, Equipment, and Supplies
(d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of three resident tooms did not have a working light or lamp which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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The administrator will ensure that the light is replaced in the room. The administrator will develop and implement a plan to ensure that the facility is checked frequently for repairs. Adminstrator will ensure that the LPA is informed of this process.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that the facility did not have the records avalible for review at the time of the inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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The administrator will develop and implement a plan to ensure that records will be complete and avalible for review at the time of inpection. The administrator will inform the LPA of this plan.
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:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/25/2024 01:52 PM - It Cannot Be Edited


Created By: Jaynae Boyles On 06/25/2024 at 01:21 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: MAINS'L - MONTEREY
FACILITY NUMBER: 045002763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in two of the three resident files reviewed did not contain a TB rest with the results which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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The Administrator will ensure that the TB test results are in the file and ready for review.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2024


LIC809 (FAS) - (06/04)
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