312700709-12-14-2023-59-AS-KMKY-CYHSYP-20231214131753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 312700709
Report Date: 12/14/2023
Date Signed: 12/14/2023 01:18:04 PM

Document Has Been Signed on 12/14/2023 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:	SIGNATURE LIVING ON MILLPORT DRIVE		FACILITY NUMBER:	312700709
ADMINISTRATOR:	KRIEG, NERRYROSE		FACILITY TYPE:	740
ADDRESS:	7641 MILLPORT DRIVE		TELEPHONE:	(916) 580-3265
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95678
CAPACITY:	6	CENSUS: 6	DATE:	12/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Caregiver		TIME COMPLETED:	01:30 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) Kevin Mknelly arrived at the facility unannounced on 12/14/23 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard.The home is very clean and residents stated they are happy with care. Water temperatures will be increased and monitored, fire door release system will be repaired prior to magnetic holders use. LPA reviewed 6 resident files. Files were incomplete. LPA reviewed 2 staff files. Files are complete. Infection control training to be conducted. Deficiencies are being cited as a result of todays inspection. Exit interview conducted with licensee and copy of report and appeal rights left at the facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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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Document Has Been Signed on 12/14/2023 01:18 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIGNATURE LIVING ON MILLPORT DRIVE	FACILITY NUMBER: 312700709
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. 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 one of six residents, R1, does not have a medication order matching current medication bottle, matching the MAR for gabapentin which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Licensee will send proof of physician contact that addresses the medication error and reconciles orders with medications to be administrated by the POC date of 12/15/23 at 5 PM.

Type A

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above in emergency drills are not conducted quarterly and with staff from all shifts which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of emergency drill conducted with all current care staff by the POC date of 12/15/23.

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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/14/2023 01:18 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIGNATURE LIVING ON MILLPORT DRIVE	FACILITY NUMBER: 312700709
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 2 of 6 residents, R1 and R3, do not have pre-appraisals on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/28/2023
	Plan of Correction
1 2 3 4	Licensee will submit copies of appraisal/ needs and services plans of R1 and R3 by the POC date of 12/28/23

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review the licensee did not comply with the section cited above in 3 of 6 resident files for R2, R3 and R5, physician report was either missing or ourt of date which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/11/2024
	Plan of Correction
1 2 3 4	Licensee will submit copies of LIC 602s for R2, R3 and R5 by the POC date of 1/11/24.

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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/14/2023 01:18 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIGNATURE LIVING ON MILLPORT DRIVE	FACILITY NUMBER: 312700709
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 2 of 6 residents, R1 and R3, do not have files set up with all required docs, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/28/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of completed files for R1 and R3 by the POC date of 12/28/23.

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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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