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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701001
Report Date: 03/08/2022
Date Signed: 03/08/2022 02:41:44 PM


Document Has Been Signed on 03/08/2022 02:41 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:A1 SENIOR CARE 2FACILITY NUMBER:
312701001
ADMINISTRATOR:TACANDONG, DAISYREEFACILITY TYPE:
740
ADDRESS:2040 SYMPHONY AVETELEPHONE:
(916) 472-4543
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
03/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Ezra Ternate, Caregiver and Jocelyn Javelana, CaregiverTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kerry Hiratsuka and Lavinia Muscan arrived at the facility unannounced on 03/08/2022 to conduct a case management visit during a complaint visit. LPAs conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPAs were screened by Caregiver.

It was discovered during today's visit the caregivers are giving insulin injections to a resident at the resident's request. The caregivers are not licensed skilled medical professionals and they are not allowed to give injections per Title 22 regulations.

Deficiency is cited on 809-D, per Title 22 Regulations, Division 6. Appeal rights were provided to the caregiver on duty.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
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 03/08/2022 02:41 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: A1 SENIOR CARE 2
FACILITY NUMBER: 312701001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2022
Section Cited

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Diabetes. The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection,
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or has it administered by an appropriately skilled professional.
This requirement was not met as evidenced by: the caregivers, who are not licensed skilled medical professionals are giving insulin injects at the resident's request. This is an immediate safety risk to residents.
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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 OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
LIC809 (FAS) - (06/04)
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