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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115002409
Report Date: 05/11/2022
Date Signed: 05/11/2022 10:15:24 AM

Document Has Been Signed on 05/11/2022 10:15 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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:
05/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Haylie Torres, staff
Nicole Elder, Adminitrator/Licensee		TIME COMPLETED:
10:30 AM
NARRATIVE
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On 5/11/2022 at 8:10 AM, Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a complaint investigation, LPA met with administrator Nicole Elder and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask.

At the time the Department arrived at the facility, the Department knocked multiple times and was greeted by two unsupervised clients. Clients said staff was sleeping and typically sleeps until 930 AM. The clients stated they have not yet had breakfast and haven't gone to day program since COVID. The Department entered the facility and sat at the kitchen table for approximately 50 minutes at which time the Department contacted the administrator/licensee Nicole Elder via phone. Community Care Licensing management was notified.

The Department requested Nicole respond to the facility immediately which she did. Staff said she was getting up and ready in the bathroom and that the clients should have notified her that someone was at the door. The licensee also stated that the clients shouldn't have opened the door and should have notified staff there was someone here.

The following deficiencies were cited per Title 22 of the California Code of Regulation (See 809D). 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 dates; civil penalties may be assessed. Civil Penalties assess in the amount of $500 for absence of supervision.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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 05/11/2022 10:15 AM - It Cannot Be Edited


Created By: Jaclyn Avila On 05/11/2022 at 09:34 AM
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: DAVID LEROY MANOR II
FACILITY NUMBER: 115002409

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2022
Section Cited
CCR
80078(a)

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80078(a) Responsibility for Providing Care and Supervision-The licensee shall provide care and supervision as necessary to meet the client's needs

This requirement is not met as evidenced by: Based upon Interview and observation:
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Licensee agrees to train staff on supervision and adjust schedules to ensure there is supervision. Policy and training will be provided to CCL no later than COB 5/12/2022
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the Licensee failed to provide supervision to 5 of 6 clients in care.

This poses an immediate Health, Safety and/or Personal Rights risk to clients in care.
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Type A
05/12/2022
Section Cited
CCR80064(a)(7)

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80064 Administrator - Qualifications and Duties(a) The administrator shall have the following qualifications:(7) Ability to recruit, employ, train, and evaluate qualified staff, and to terminate employment of staff, if applicable to the facility.
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Licensee agrees to conduct quality assurance visits to the facility during morning hours to ensure staff are in compliance with regulations. Policy and schedule will be provided to CCL by COB on 5/12/2022.
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This requirement is not met as evidenced by: Based upon Interview and observation: the Licensee failed to provide qualified staff to meet the needs of 5 of 6 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:Laura Munoz
LICENSING EVALUATOR NAME:Jaclyn Avila
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022


LIC809 (FAS) - (06/04)
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