312700395-12-22-2021-25-AS-KHIA-C9XUZN-20211222150149

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 312700395
Report Date: 12/22/2021
Date Signed: 12/22/2021 03:02:01 PM

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:	A1SENIOR CARE		FACILITY NUMBER:	312700395
ADMINISTRATOR:	TACANDONG, DAISYREE		FACILITY TYPE:	740
ADDRESS:	217 HINGHAM CT		TELEPHONE:	(916) 740-7715
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY:	6	CENSUS: 6	DATE:	12/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Courtney King, Caregiver		TIME COMPLETED:	03:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) K.. Hiratsuka and Talwinder Bains , arrived at the facility unannounced on 12/22/2021 to conduct an unannounced annual visit using the infection control tool visit. LPAs met with Facility Caregiver Courtney King, and explained the purpose of the visit. Prior to initiating the visit, LPAs 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.. LPAs ensured hand hand sanitizer shortly after entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Caregiver. LPAs and Caregiver 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 restroom. LPAs and Caregiver completed the infection control domain and the facility was not in compliance with parts of the infection control domain. LPA Hiratsuka, spoke to Administrator Daisyree Tacandong, over the phone during visit. The following issues were found and discussed during the phone call with Administrator. Administrator stated she will get the below done. They are not cited. : -No required Covid 19 precaution posters were posted in the facility and front door. -the staff have not been fit tested for N95 respirators to ensure proper fit -no staff screening logs -no resident screening logs

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: A1SENIOR CARE	FACILITY NUMBER: 312700395
	VISIT DATE: 12/22/2021

NARRATIVE

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The following citation was issued and a civil penalty of $500.00 was issued immediately:
-a lock that has not been approved by the fire department and Community Care Licensing Division is on the front door preventing residents from getting out. This lock is not part of the approved door lock for the door. This lock is positioned above the approved door lock. This is a fire hazard because it it not approved. It was explained there is a resident who wanders and it prevents the resident from leaving This is also a possible level of care issue because due to the resident conditions, the resident(s) may not be appropriate for this facility. Licensee shall address the issue. If Licensee wants to use the lock, then she shall submit to Community Care Licensing Division a waiver request for a locked perimeter and also shall submit for a fire clearance. Lock shall be removed as soon as possible and not used until removed.

Deficiency is cited on 809-D, per Title 22 Regulations, Division 6. Civil penalties of $500.00 was issued immediately and shall accrue at $100.00 per day until Licensee informs Community Care Licensing Division the citation is corrected.

Appeal rights were provided to Caregiver.

Exit interview conducted and copy of report left at the facility.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: A1SENIOR CARE	FACILITY NUMBER: 312700395
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: 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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.Thsi facility does not have a locked perimeter fire clearance and the front door has a lock that is not approved by the fire department and Community Care Licensing Division. This is an immediate health and safety risk
	POC Due Date: 12/23/2021
	Plan of Correction
1 2 3 4	The licensee shall come up witha plan of correction addressing the lock on the door that is not approved by the fire department and Community Care Licensing Divsion. If the licensee wishes to keep the lock the licensee shall apply for a locked perimeter fire clearance and the lock shall not be used until the issue is resolved. If the Licensee does not want a locked perimeter fire clearance the lock shall be removed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC809 (FAS) - (06/04)

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