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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701014
Report Date: 10/12/2022
Date Signed: 10/12/2022 05:06:36 PM


Document Has Been Signed on 10/12/2022 05:06 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:LOREDANA CARE HOME 2FACILITY NUMBER:
312701014
ADMINISTRATOR:HEGSETH, NICOLETAFACILITY TYPE:
740
ADDRESS:1080 PORTER DRTELEPHONE:
(916) 891-7065
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 2DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Geta PopTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on10/12/22 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA 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 and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Geta "Laurie" Pop arrived to assist with the 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. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and licensees followed the infection control domain guidelines and facility was found to be in substantial compliance at this time.

Records and staff review found that as of 10/8/22, in response to previous caregivers unexpectedly quitting, the two (2) staff working, S1 and S2, were hired before receiving criminal record clearance.
Citation and civil penalties are applied. The caregiver are temporarily replaced with staff from another RCFE and transfer request was submitted.
LPA reviewed R1's file and it was complete. LPA and licensee discussed signed medication orders and PRN Authorization letters
Licensee received a copy of liability insurance certificate .
A Deficiency and civil penalties are being cited as a result of todays inspection for criminal record clearance. Exit interview conducted and copy of report and appeal rights left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
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 10/12/2022 05:06 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: LOREDANA CARE HOME 2
FACILITY NUMBER: 312701014

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)(B)
Personnel Records
(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
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Based onrecords and interview, the licensee did not comply with the section cited above in 2 out of 2 caregivers present which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Licensee removed the caregivers from the premises unless and untill they are cleared and associated. Licensee arranged for alternative staffing and provided LPA with a transfer request. Licensee will submit a statement of understanding of this requirement by 10/13/22.
Civil Penalties applied.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
LIC809 (FAS) - (06/04)
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