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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002763
Report Date: 02/14/2023
Date Signed: 03/14/2023 09:25:35 AM

Document Has Been Signed on 03/14/2023 09:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MAINS'L - MONTEREYFACILITY NUMBER:
045002763
ADMINISTRATOR:FORGE, VIOLAFACILITY TYPE:
735
ADDRESS:278 PANAMA AVETELEPHONE:
(530) 899-1907
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY: 5CENSUS: 1DATE:
02/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:COURTNEY DUGANTIME COMPLETED:
09:40 AM
NARRATIVE
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Case Management inspection completed by Donna Gurriere, Licensing Program Analyst (LPA). The purpose of this visit is to meet with staff to discuss and cite regarding a recent visit from Far Northern Region Center (FNRC) regarding citations that they issued on 01/12/23.

LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility.

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SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: MAINS'L - MONTEREY
FACILITY NUMBER: 045002763
VISIT DATE: 02/14/2023
NARRATIVE
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Citations issued by FNRC include the following:

1. Resident 1 is being left alone in the facility without supervision.
2. Resident 1 has a fish allergy that requires clarification from her physician.
3. Resident 1 uses a C-Pap machine; however, staff have not had comprehensive training.
4. Resident 2 did not have a current Personal and Incidental (P&I) ledger on file at the facility.
5. Resident 2 staff did not submit an incident report to the regional center regarding a resident missing their medication dosages.

Based on documents received from the regional center, the licensee shall be cited. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D pages.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date; civil penalties may be assessed.



continued
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
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Page: 4 of 4
Document Has Been Signed on 03/14/2023 09:25 AM - It Cannot Be Edited


Created By: Donna Gurriere On 02/22/2023 at 01:05 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: MAINS'L - MONTEREY
FACILITY NUMBER: 045002763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2023
Section Cited
CCR
80078(a)

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Responsibility for Providing Care and Supervision – The licensee shall provide care and supervision as necessary to meet the client's needs.
The licensee did not ensure that Resident 1 had supervision in the facility, as he was left alone.
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The licensee shall develop a plan to advise how this citation will be avoided in the future.
Type A
03/15/2023
Section Cited
CCR
85075(b)

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Health Related Services – The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.
The licensee did not ensure that there was clarification from the physician as to if the resident’s EpiPen was for the fish allergy or a bee sting.
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The licensee shall develop a plan to advise how this citation will be avoided in the future.
Type A
03/15/2023
Section Cited
CCR80065(f)

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Personnel Requirements – All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.
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The licensee shall advise the licensing agency those staff that have been trained regarding the C-Pap machine and what the training consisted of.
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The licensee did not ensure that the staff had the appropriate training as to how to clean or use a C-Pap machine.
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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:Donna Gurriere
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/14/2023 09:25 AM - It Cannot Be Edited


Created By: Donna Gurriere On 02/22/2023 at 01:14 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: MAINS'L - MONTEREY
FACILITY NUMBER: 045002763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2023
Section Cited
CCR
80070(a)(14)

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Client Records – An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026…
The licensee did not ensure that the resident’s P&I ledger was up to date.
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The licensee shall develop a plan to advise how this citation will be avoided in the future.
Type B
03/15/2023
Section Cited
CCR
80075(b)

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Health Related Services – Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
The licensee did not ensure that the resident received their medication.
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The licensee shall develop a plan to advise how this citation will be avoided in the future.

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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:Donna Gurriere
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023


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