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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708872
Report Date: 11/18/2023
Date Signed: 11/19/2023 06:05:19 PM


Document Has Been Signed on 11/19/2023 06:05 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:CRISTINE'S GUEST HOMEFACILITY NUMBER:
270708872
ADMINISTRATOR:DEL ROSARIO, MA. CRISTINAFACILITY TYPE:
740
ADDRESS:458 RAINIER DRIVETELEPHONE:
(831) 998-7544
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY:6CENSUS: 6DATE:
11/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Facility staff, Genovera BoseTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with facility staff Genovera Bose, Continual Administrator's Certification expires for Cristina Del Rosario expired on 06/23/23. There are currently 6 residents who reside at this home and there is 0 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. There is a locked storage for medications.
Fire extinguisher is within the safety regulation period. Toxins and cleaning supplies are locked and inaccessible.
Administrator Cristina Del Rosario does not have a current Administrators Certificate. LPA observed a lock on the inside of the door approximately 8 foot high out of reach of facility residents. Facility staff stated they use the lock at night to prevent a resident from wondering and leaving the facility. The facility does not have a complete first aid kit. LPA observed a box of large band aids, and a thermometer inside a bag that facility staff presented as the "first aid kit." LPA observed cobwebs with spiders throughout the facility including in the kitchen area near the stove and food being prepared. Water temperature was tested at 122 degrees. LPA observed food expired inside the refrigerator including a ranch bottle that expired in 2017. The facility refrigerator appeared to be dirty. LPA observed the facility bathroom trash overflowing with no lid. LPA observed a chair in resident bedroom to be extremely dirty. This facility does not have a current Emergency Disaster Plan. This facility does not have a current updated resident roster. The home does not have a carbon monoxide detector and does not performs disaster drills as required. The facility backyard has clutter including old mattresses, and car parts. LPA observed facility staff preparing residents lunch of peanut butter with bread, and canned green beans. The facility does not have required adequate 2 day perishable food supply. LPA observed facility staff 1 preparing chicken in a container labeled "ground beef." LPA observed the chicken on the counter at room temperature for more than 2 hours the entire duration of the visit.

Continued...
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CRISTINE'S GUEST HOME
FACILITY NUMBER: 270708872
VISIT DATE: 11/18/2023
NARRATIVE
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Continued...


LPA observed Resident 1 does not have a Centrally Stored Medication Log.
LPA observed Resident 1 does not have a signed Admission Agreement. Staff 1 does not have a current CPR/First aid as required.

LPA Hurt will return at a later date to complete this inspection.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Facility staff Genovera Bose and copy of report left at facility

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2023 06:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: CRISTINE'S GUEST HOME

FACILITY NUMBER: 270708872

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPA observed resident hallway bathroom water temperature to measure 121 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2023
Plan of Correction
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2
3
4
Licensee will ensure water temperature is between 105 and 120 degrees within Title 22 Regulation and submit proof to LPA by POC date of 11/19/23.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in based on records reviewed facility Staff 1 does not have required first aid/CPR training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2023
Plan of Correction
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3
4
Licensee will ensure staff 1 is CPA/First aid certified and send proof to LPA by POC date of 11/19/23.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2023 06:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: CRISTINE'S GUEST HOME

FACILITY NUMBER: 270708872

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(4)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in based on observation this facility is dirty, and not in good repair, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2023
Plan of Correction
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2
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4
The Licensee will deep clean all areas of this facility including remove cobwebs with insects from kitchen, and bathroom areas, clean facility refrigerator, clean facility floors, and carpets.
Type A
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review , the licensee did not comply with the section cited above in Resident 1 does not have a signed Admission Agreement which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2023
Plan of Correction
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Licensee will provide a signed Admission Agreement for Resident 1 and send to LPA by POC date of 11/19/23.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2023 06:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: CRISTINE'S GUEST HOME

FACILITY NUMBER: 270708872

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed raw chicken left on the counter for several hours, and in a container labeled "ground beef", several moldy and expired bags of food inside the facility refrigerator, the inside of the facility refrigerator appears to be dirty, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2023
Plan of Correction
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Licensee will deep clean the facility refrigerator, and conduct food handling, and service training to facility staff, and send proof to LPA Hurt by POC date of 11/19/23.
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation, the licensee did not comply with the section cited above in the facility does not have required perishable food supply, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2023
Plan of Correction
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Licensee will provide required 2 day perishable food supply and submit to LPA by POC date of 11/19/23.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2023
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 11/19/2023 06:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: CRISTINE'S GUEST HOME

FACILITY NUMBER: 270708872

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in Resident 1 does not have a centrally stored medication log, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2023
Plan of Correction
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Licensee will provide current Centrally Stored Medication Log for facility Resident 1, and send proof to LPA by POC date of 11/19/23
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2023 06:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: CRISTINE'S GUEST HOME

FACILITY NUMBER: 270708872

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in based on observation this facility is dirty, and not in good repair, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2023
Plan of Correction
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3
4
The Licensee will ensure this facility including bathrooms, resident bedrooms, kitchen, and living areas is deep cleaned and free of cobwebs, and insects. Licensee will ensure the facility bathroom floors are cleaned and free of mold.Licensee will ensure the trash in the backyard is removed and send proof to LPA by POC date of 11/19/23.
Type B
Section Cited
CCR
87303(f)(3)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in based on observation resident bathroom trash bins are overflowing and have no lid, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2023
Plan of Correction
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Licensee will provide required waste bins and send proof to LPA by POC date of 12/02/23
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2023
LIC809 (FAS) - (06/04)
Page: 7 of 9


Document Has Been Signed on 11/19/2023 06:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: CRISTINE'S GUEST HOME

FACILITY NUMBER: 270708872

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(8)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on obseravtion, the licensee did not comply with the section cited above in this facility does not have a complete first aid kit as required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2023
Plan of Correction
1
2
3
4
Licensee will supply a complete first aid kit as required in Title 22 Regulations, and send proof to LPA by POC date of 12/02/23.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, and observation the licensee did not comply with the section cited above in facility does not have an updated Emergency Disaster plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2023
Plan of Correction
1
2
3
4
Licensee will provide current, updated Emergency Disaster plan and submit to LPA by POC date of 11/19/23
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2023 06:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: CRISTINE'S GUEST HOME

FACILITY NUMBER: 270708872

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(1)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation,and record review the licensee did not comply with the section cited above in based on facility staff present could not provide current resident roster, which poses a potential, health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2023
Plan of Correction
1
2
3
4
Licensee will provide an updated and current resident roster to LPA by POC date of 12/02/23
Type B
Section Cited
CCR
87405(a)

87405 Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in Licensee's Adminstrators Certificate expired on 06/23/23, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2023
Plan of Correction
1
2
3
4
Licensee will submit proof of current Administrators Certificate to LPA by POC date of 12/02/23.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2023
LIC809 (FAS) - (06/04)
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