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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
315002194
Report Date:
08/28/2023
Date Signed:
08/28/2023 04:01:54 PM
Document Has Been Signed on
08/28/2023 04:01 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:
LINCOLN RESIDENCE 1408
FACILITY NUMBER:
315002194
ADMINISTRATOR:
GRACE HAWKINS
FACILITY TYPE:
740
ADDRESS:
1408 ALDER CREEK COURT
TELEPHONE:
(916) 543-1338
CITY:
LINCOLN
STATE:
CA
ZIP CODE:
95648
CAPACITY:
6
CENSUS:
6
DATE:
08/28/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:15 PM
MET WITH:
Grace Hawkins
TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Melissa Parks and Sarah Benson arrived on Monday August 28, 2023 to complete the unannounced annual inspection.
During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (6) and staff files (2). All resident files contained the required paperwork except 5 residents were missing TB tests/results. Staff files contained the required paperwork. Two staff files reviewed did not contain current CPR/First aid. LPAs were unable to review the facility's fire drill log as no fire drills have been conducted in the past two years.
LPA Parks and Benson and Administrator Grace toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, garage and outdoor area. Water temperatures in both bathrooms measured 129 and 132 degrees F. Facility meets the perishable and nonperishable food requirements. LPAs observed a facility closet being used as a staff living quarters. An immediate $500 civil penalty was issued.
See 809-D pages for deficiencies cited during todays visit.
Appeal rights were given. Exit interview conducted. A copy of this report was emailed to Facility.
SUPERVISOR'S NAME:
Maribeth Senty
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Melissa Parks
TELEPHONE:
(559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE:
08/28/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/28/2023
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
4
Document Has Been Signed on
08/28/2023 04:01 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:
LINCOLN RESIDENCE 1408
FACILITY NUMBER:
315002194
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 bathroom water temperatures which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/29/2023
Plan of Correction
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Administrator to send a statement of understanind by end of day 8/29/2023. Administrator to take water temperatures twice a day, for 7 days, and send record to LPA.
Type A
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above by allowing staff to live in hallway closet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/29/2023
Plan of Correction
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Administrator to send LPA pictures of closet empty of staff personal belongings.
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:
Melissa Parks
TELEPHONE:
(559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE:
08/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/28/2023
LIC809
(FAS) - (06/04)
Page:
2
of
4
Document Has Been Signed on
08/28/2023 04:01 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:
LINCOLN RESIDENCE 1408
FACILITY NUMBER:
315002194
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff records reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/11/2023
Plan of Correction
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Administrator to email LPA copies of staff current first aid/cpr training
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out 6 clients not having TB records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/28/2023
Plan of Correction
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Administrator to submit copies of missing TB records for 5 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
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Melissa Parks
TELEPHONE:
(559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE:
08/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/28/2023
LIC809
(FAS) - (06/04)
Page:
3
of
4
Document Has Been Signed on
08/28/2023 04:01 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:
LINCOLN RESIDENCE 1408
FACILITY NUMBER:
315002194
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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2
3
4
Based on record review the licensee did not comply with the section cited above by not having any fire drills within the past two years which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/11/2023
Plan of Correction
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3
4
Administrator to submit statement of understaning regarding regulation. Administrator to submit record of one fire drill.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:
Melissa Parks
TELEPHONE:
(559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE:
08/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/28/2023
LIC809
(FAS) - (06/04)
Page:
4
of
4