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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052700992
Report Date: 08/17/2023
Date Signed: 08/17/2023 01:41:16 PM


Document Has Been Signed on 08/17/2023 01:41 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:FOOTHILL VILLAGE SENIOR LIVINGFACILITY NUMBER:
052700992
ADMINISTRATOR:BITLER, MAUREEN H.FACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY:78CENSUS: 69DATE:
08/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Angelica White TIME COMPLETED:
02:00 PM
NARRATIVE
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On 08/17/2023, Licensing Program Analyst (LPA) Kimberly Viarella, and Licensing Program Manager (LPM), Liza King made an unannounced visit to this facility to follow up on a complaint. The LPA identified herself and the purpose of the visit and asked to speak to the Designated Facility Representative. The LPA met with Angelica White and a brief interview followed. This case management is a result of observations made during the tour of the facility.

During a walk through of the memory care unit, the LPM entered 2 residents' unlocked rooms and found the following: Lysol toilet bowl cleaner, disinfectant air freshener, various body creams, Ajax, liquid soaps, Dawn dish soap, hydrogen peroxide, Bactine, skin cleaners, aerosol hairspray, shampoo, conditioners, and razors.

While LPA/LPM were still present at the facility, staff completed a sweep of the entire dementia care unit to remove similar toxins. Memory Care Director stated that shower caddies will be implemented to contain and monitor all toxic hygiene items. This caddies will be stored in a locked storage room and accessible only to staff. The Memory Care Director also agreed to revisit all LIC 602s for memory care residents in order to develop a system for identifying which residents were allowed access to hygiene items as well as a system for re-appraising this capability.

The following deficiency was cited on the LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

A copy this report, along with the Appeal Rights were provided to the Director of Memory Care.

Exit interview.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
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 08/17/2023 01:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2023
Section Cited
CCR
87705(f)(2)

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Care for Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication... vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening...
This requirement is not met as evidenced by:
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Staff completed a sweep of the memory care unit before this case management was concluded. Licensee shall implement shower caddies to contain and monitor toxic hygiene items. Caddies will be stored in a locked laundry room and inaccessible to residents in care.
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Based on an inspection of 2 unlocked resident rooms in the dementia care unit, the LPM observed 30 toxic substances.
The licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
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LIC 602s will also be revisited to identify which residents may have access to hygiene items if kept in a private locked bedroom.

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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: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
LIC809 (FAS) - (06/04)
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