052701150-8-4-2023-27-AS-RCAL-CUDT4L-20230804142408

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 052701150
Report Date: 08/04/2023
Date Signed: 08/04/2023 02:25:34 PM

Document Has Been Signed on 08/04/2023 02:25 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	KAREN CARES HOME		FACILITY NUMBER:	052701150
ADMINISTRATOR:	PUENTE, KAREN		FACILITY TYPE:	735
ADDRESS:	2378 VISTA DEL LAGO		TELEPHONE:	(209) 584-9047
CITY:	VALLEY SPRINGS	STATE: CA	ZIP CODE:	95252
CAPACITY: 4		CENSUS: 3	DATE:	08/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Karen Puente, Administrator		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/04/23, LPA Renee Campbell arrived at approximately 8:45 am to conduct an annual inspection. LPA Campbell was greeted by Direct Service Provider (DSP) Kelsey Gharabawy and stated the purpose of the visit. The Licensee/Administrator Karen Puente arrived 15 minutes later. The facility is a Residential Adult Facility and is licensed for a capacity of 4 clients and currently has a census of 3 clients 2 of whom were in day programs. LPA Campbell entered the residence through the garage and into the kitchen. Floors were clean and unobstructed. The room temperature was 74 degrees Fahrenheit and the water temperature was 113 degrees Fahrenheit. LPA Campbell entered the dining room to set up a work space. In the dining room, a cork board contained the license, emergency disaster plan and Personal Rights for Adult Community Care Facilities. Daily Goals for each client were pinned up on a separate cork board. Licensee and LPA toured the facility. The living room had a screened fire place. When asked, licensee stated the fireplace was never used. There were three bedrooms for four clients. One bed was a double bed and the rest were twin beds. Rooms contained a closet, night table, lamps as well as a chest of drawers. Client bedrooms also contained artwork and collections they had selected themselves. There were two client bathrooms. There is also one staff bathroom in the staff lounge that is used for staff who may work overnight. There are no live in staff. Bathrooms had grab bars and bath mats. Licensee presented their Infection Control Plan and Plan of Operations. The fire extinguisher had a receipt for date of purchase that could not be deciphered and was deemed out of compliance. During today's visit, The licensee purchased a new extinguisher and agreed to take this and all future extinguisher's to the fire department for inspection. A Record of Fire Drills were reviewed. The facility completed fire drills monthly with all residents present and the appropriate number of staff.

SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

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 3

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: KAREN CARES HOME	FACILITY NUMBER: 052701150
	VISIT DATE: 08/04/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308)
Liability Insurance
Administrator Certificate-Updated
Personnel Report (LIC500)

Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, deficiencies were observed during today’s visit. Citations can be found on the LIC 809 – D. Failure to correct deficiencies may result in civil penalties.

Appeal rights were printed and a copy was given to the facility designated Administrator.
Exit Interview was conducted and copy of the LIC 809, LIC 809-C, LIC 809-D and appeals rights were given to the facility at the end of the visit.

SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 08/04/2023 02:25 PM - It Cannot Be Edited

Created By: Renee Campbell On 08/04/2023 at 02:10 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: KAREN CARES HOME	FACILITY NUMBER: 052701150
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

80020(a)

All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not ensure the fire extinguisher is up to date.The Fire extinguisher was last serviced 04/27/2023. This posed an immediate health and safety risk to residents in care.
	POC Due Date: 08/07/2023
	Plan of Correction
1 2 3 4	Licensee purchased a new fire extinguisher during inspection visit with a receipt date of 08/04/23. Licensee agrees to take this fire extinguisher in to be inspected at the fire department by POC date and provide images of the inspection tag to renee.campbell@dss.ca.gov .

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Emerita Curiel

LICENSING EVALUATOR NAME:

Renee Campbell

LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3