315002127-5-25-2023-59-AS-IAVA-CS6RKR-20230525130557

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 315002127
Report Date: 05/25/2023
Date Signed: 05/25/2023 01:06:03 PM

Document Has Been Signed on 05/25/2023 01:06 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME:	GREEN MOUNTAIN VILLA		FACILITY NUMBER:	315002127
ADMINISTRATOR:	HANDY KUSUMAH		FACILITY TYPE:	740
ADDRESS:	5853 GREEN MOUNTAIN LANE		TELEPHONE:	(916) 315-9167
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95677
CAPACITY: 6		CENSUS: 4	DATE:	05/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:13 AM
MET WITH:	Administrator Silvia Gonie		TIME COMPLETED:	01:35 PM

NARRATIVE

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On 05/25/2023, Licensing Program Analysts (LPA) Ivan Avila, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Silvia Gonie and explained the purpose of the visit.

LPA Avila and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, backyard, shed, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 111 F. LPA observed one (1) fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of four (4) residents' files and one (1) staff files.

Several topics were discussed.

The CARES tool was utilized based on observations from today's visit and deficiencies were cited at this visit accordingly.

Appeal rights given.

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

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

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 05/25/2023 01:06 PM - It Cannot Be Edited

Created By: Ivan Avila On 05/25/2023 at 12:55 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: GREEN MOUNTAIN VILLA	FACILITY NUMBER: 315002127
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/25/2023

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 observation, the licensee did not comply with the section cited above. There was no signed admission agreements for three residents on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/01/2023
	Plan of Correction
1 2 3 4	The licensee shall compile and retain complete resident records for all residents that are accepted or retained in the facility. These files shall be available for review for licensing upon request. Send proof of correction of missing information in resident records by June 1, 2023 to the Department.

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:

Lauren Crocker

LICENSING EVALUATOR NAME:

Ivan Avila

LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC809 (FAS) - (06/04)

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