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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 181370671
Report Date: 03/22/2024
Date Signed: 03/22/2024 01:18:54 PM

Document Has Been Signed on 03/22/2024 01:18 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:MOUNTAIN JEWELS HOMEFACILITY NUMBER:
181370671
ADMINISTRATOR:HOFFMAN, MARIEFACILITY TYPE:
735
ADDRESS:527-960 LITTLE VALLEY RD.TELEPHONE:
(530) 336-6987
CITY:MCARTHURSTATE: CAZIP CODE:
96056
CAPACITY: 10CENSUS: 5DATE:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marie Hoffman AdministratorTIME COMPLETED:
01:30 PM
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On 03/22/2024 11:00 AM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Marie Hoffman administrator (cert #6051700731 exp.11-24-25) and explained the purpose of the visit. Administrator certificate is current.

LPA Benson and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to seven (7) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet.



The common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food.

The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities planned for the clients. All required postings are displayed within the facility.

The firearms are locked and ammunition is locked in a separate room on premises. The last disaster drill was conducted and documented on 03-20-24, the facility has been conducting drills every 3 months.

The facility is in compliance. No deficiencies are being cited as a result of today’s inspection.



Exit interview conducted and copy of report was provided to administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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 03/22/2024 01:18 PM - It Cannot Be Edited


Created By: Sarah Benson On 03/22/2024 at 01:10 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MOUNTAIN JEWELS HOME
FACILITY NUMBER: 181370671

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview and record review the licensee did not comply with the section cited above in 2 out 2 staff had expired 1st aid which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2024
Plan of Correction
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Staff will take 1st aid trainning and receive 1st aid cert.
Administrator will email LPA when completed.
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview and record review the licensee did not comply with the section cited above in 1 out of 3 clients did not have a TB test record in client file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2024
Plan of Correction
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Administrator will get TB test. results.
Administrator will email LPA when complete
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:Sarah Benson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
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