Community Care Licensing

SUPERVISOR'S NAME: Brenda Chan TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Sarah Hurt TELEPHONE: 559-243-8080 LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024

Document Has Been Signed on 03/05/2024 10:34 PM - It Cannot Be Edited

FACILITY NAME: CRISTINE'S GUEST HOME	FACILITY NUMBER: 270708872
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2024

Type A

Section Cited

CCR

87412(a)(13)(B)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 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 Staff 1 is not fingerprint cleared, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2024
	Plan of Correction
1 2 3 4	LPA Hurt informed Licensee Cristina DelRosario, facility live in Staff 1 is to leave the facility, and is not to provide care for residents.

Type A

Section Cited

CCR

87555(b)(8)

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. 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 several cans of expired food including sardines, spam, and chicken and dumplings, dated as far back as 2021, 2022, 2023. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/22/2024
	Plan of Correction
1 2 3 4	Facility staff will immediately dispose of expired foods.

SUPERVISOR'S NAME: Stephenie Doub TELEPHONE: (916) 263-2131 LICENSING EVALUATOR NAME: Sarah Hurt TELEPHONE: (916) 879-2602 LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024

Document Has Been Signed on 03/05/2024 10:35 PM - It Cannot Be Edited

FACILITY NAME: CRISTINE'S GUEST HOME	FACILITY NUMBER: 270708872
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2024

Type A

Section Cited

CCR

87555(b)(26)

(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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the facilities non perishable food supply was mostly expired, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/22/2024
	Plan of Correction
1 2 3 4	Licensee will provide sufficient food supply, and send proof to LPA Hurt by POC date of 02/21/2024.

Type A

Section Cited

CCR

87411(a)(b)(c)(1)

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. (b) All persons who supervise employees or who supervise or care for residents shall be at least eighteen (18) years of age. (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 Staff 2 does not have required first aid training, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/22/2024
	Plan of Correction
1 2 3 4	Licensee will send proof Staff 2 has required first aid training to LPA by POC date 02/22/2024.

SUPERVISOR'S NAME: Stephenie Doub TELEPHONE: (916) 263-2131 LICENSING EVALUATOR NAME: Sarah Hurt TELEPHONE: (916) 879-2602 LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024

Document Has Been Signed on 03/05/2024 10:35 PM - It Cannot Be Edited

FACILITY NAME: CRISTINE'S GUEST HOME	FACILITY NUMBER: 270708872
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2024

Type B

Section Cited

CCR

87303(a)

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. 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 the facility showers, bathroom floors, carpet are dirty and in disrepair, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2024
	Plan of Correction
1 2 3 4	Licensee will clean facility flooring and send proof to LPA by POC date of 03/07/2024.

Type B

Section Cited

CCR

87303(c)

(c) All window screens shall be clean and maintained in good repair. 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 several facility window screens are ripped and in disrepair, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2024
	Plan of Correction
1 2 3 4	Licensee will repair broken and ripped window screens, and send proof to LPA by POC date of 03/07/2024.

SUPERVISOR'S NAME: Stephenie Doub TELEPHONE: (916) 263-2131 LICENSING EVALUATOR NAME: Sarah Hurt TELEPHONE: (916) 879-2602 LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024

Document Has Been Signed on 03/05/2024 10:35 PM - It Cannot Be Edited

FACILITY NAME: CRISTINE'S GUEST HOME	FACILITY NUMBER: 270708872
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2024

Type B

Section Cited

CCR

87507(d)

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. 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 signed Admission Agreement in file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	Licensee will provide signed Admission Agreement for Resident 1, and send proof to LPA by POC date of 03/07/2024.

Section Cited

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

SUPERVISOR'S NAME: Stephenie Doub TELEPHONE: (916) 263-2131 LICENSING EVALUATOR NAME: Sarah Hurt TELEPHONE: (916) 879-2602 LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024