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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115002409
Report Date: 12/08/2023
Date Signed: 12/08/2023 03:43:08 PM

Document Has Been Signed on 12/08/2023 03:43 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:DAVID LEROY MANOR IIFACILITY NUMBER:
115002409
ADMINISTRATOR:NICOLE ELDERFACILITY TYPE:
735
ADDRESS:900 FIFTH STTELEPHONE:
(530) 356-5011
CITY:ORLANDSTATE: CAZIP CODE:
95963
CAPACITY: 6CENSUS: 6DATE:
12/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator- Nicole ElderTIME COMPLETED:
04:00 PM
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On 12/08/2023, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Nicole Elder 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, and common restrooms.

LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, and trash can with lids.

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 or around 112 F in three different locations throughout the facility.

LPA observed three (3) fire extinguishers and fire detectors. The administrator could not provide documentation that the carbon monoxide detectors are interconnected with the fire detector and sprinkler system. Administrator will update the facility 610 D form and provide it to the Department.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of six (6) residents' files and three (3) staff files which contained all the required documentation.

Several topics were discussed.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.



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: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
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 12/08/2023 03:43 PM - It Cannot Be Edited


Created By: Jaynae Boyles On 12/08/2023 at 03:27 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: DAVID LEROY MANOR II
FACILITY NUMBER: 115002409

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that there is no documents to support that there is a working cabon monoxide detector at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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The administrator will have the sprinkler fire detector/carbon monoxide system serviced or provide the department with documentation that indicates that the sprinkler fire detector/carbon monoxide system is interconnected and functioning properly or will place carbon monoxide detectors at the facility.
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: 12/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023


LIC809 (FAS) - (06/04)
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