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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052701102
Report Date: 01/16/2025
Date Signed: 01/16/2025 03:25:00 PM

Document Has Been Signed on 01/16/2025 03:25 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FOOTHILL LIVING CARE HOMEFACILITY NUMBER:
052701102
ADMINISTRATOR/
DIRECTOR:		NGUYEN, ROSAURORAFACILITY TYPE:
735
ADDRESS:8269 SPARROWK ROADTELEPHONE:
(209) 341-9680
CITY:VALLEY SPRINGSSTATE: CAZIP CODE:
95252
CAPACITY: 4CENSUS: 4DATE:
01/16/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Rosaaurora NguyenTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 1-16-24 at 1:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding incident reports dated 10/7/24 and 11/5/24. LPA met with Administrator Rosaaurora Nguyen and explained the purpose of the visit. LPA conducted brief interview with resident1 (R1), Administrator, and staff1 (S1). LPA also reviewed facility file documentation including individualized program plan (IPP) for resident1 (R1), physician's report for R1, and medication records for R2.

Incident #1: On 11-5-24, Licensee reported that R1 disclosed that she had a described inappropriate interaction with another individual while on an outing 11/1/2024. Based on the nature of the interaction, Licensee reported incident to Licensing department and local law enforcement within appropriate regulatory time frames. Further review of R1's records revealed R1 is able to leave facility unassisted and Licensee was aware of R1's whereabouts.

Incident #2: On 10-7-24, Licensee reported that R2 was given medication at the incorrect time on 10-4-24 by S1. LPA reviewed medication log sheets to verify accuracy of medications and determined physician's orders matched medication log sheets. Licensee notified licensing department and R2's responsible party within regulatory time frames. Based on interview conducted it was revealed that R2 did not experience complications as a result of the medication error. LPA verified completed medication training for R2.

As a result of today's case management, citation is issued under Title 22, Division 6. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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 01/16/2025 03:25 PM - It Cannot Be Edited


Created By: Michael Bilger On 01/16/2025 at 02:35 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: FOOTHILL LIVING CARE HOME
FACILITY NUMBER: 052701102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
80075(b)

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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 will ensure completed staff training on procedures for assisting residents with medication with focus on rights of medication assistance.
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Based on interview and record review, R2 received prescribed medications at incorrect times. This posed a potential health and safety risk to residents in care.
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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 King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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