<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002127
Report Date: 04/03/2024
Date Signed: 04/03/2024 11:36:41 AM

Document Has Been Signed on 04/03/2024 11:36 AM - 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:GREEN MOUNTAIN VILLAFACILITY NUMBER:
315002127
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		HANDY KUSUMAHFACILITY TYPE:
740
ADDRESS:5853 GREEN MOUNTAIN LANETELEPHONE:
(916) 315-9167
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY: 6CENSUS: 3DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Silvia GonieTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
12:15 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) Melissa Parks arrived on Wednesday April 3, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (3) and staff files (2). Resident files did not contain current needs and services appraisals. All staff files contained the required paperwork. The last documented staff training was conducted in 2022.

LPA Parks and Administrator Silvia toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, living room, kitchen, garage and backyard. In the areas toured, there were no health or safety violations observed.

First aid kit is fully stocked. All required posting were observed. Fire extinguishers have current inspection tags.

LPA obtained paperwork to associate Silvia as Administrator.

See 809-D for deficiencies cited during todays visit. Exit interview conducted. A copy of this report was emailed to the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/03/2024 11:36 AM - It Cannot Be Edited


Created By: Melissa Parks On 04/03/2024 at 11:23 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GREEN MOUNTAIN VILLA
FACILITY NUMBER: 315002127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff not having annual training for 2023 and 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
1
2
3
4
Administrator to submit proof training for 2 staff including Dementia and medication training.
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 3 needs and services appraisals being out of date which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
1
2
3
4
Administrator to submit updated LIC 625s for all three residents.
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
LICENSING EVALUATOR NAME:Melissa Parks
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2