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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002795
Report Date: 10/08/2024
Date Signed: 10/08/2024 02:44:11 PM

Document Has Been Signed on 10/08/2024 02:44 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:A ALWAYS LOVING CARE HOMEFACILITY NUMBER:
315002795
ADMINISTRATOR/
DIRECTOR:		RAI, BALWINDERFACILITY TYPE:
740
ADDRESS:1422 ORWELL DR.TELEPHONE:
(360) 560-1818
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 5DATE:
10/08/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Balwinder Rai, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 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
On 10/08/2024 at 02:00PM, an informal conference was conducted virtual via Microsoft Teams Meeting. The purpose of this informal conference meeting is to discuss the complaint findings on 05/02/24. Present in the meeting is, Licensing Program Manager (LPM) Troy Ordonez, Licensing Program Manager (LPM) Anthony Perez, Licensing Program Analyst (LPA) Bethany Mirlohi, Licensing Program Analyst (LPA) Cassandra Mikkelson and Licensee/Administrator Balwinder Rai.

The purpose of the informal conference is to have open discussion concerning a complaint that was substantiated for a Resident who sustained (2) stage IV pressure injuries. During this meeting the licensee was made aware that this Informal conference is a part of the Administrative Action process.

The informal conference process was explained during this meeting. Issues discussed during the meeting were:


1. Care and Supervision: The Licensee shall provide care and supervision as necessary to meet the client’s needs.
2. Monitoring Resident’s Condition: Failure to Observe and Supervise the Progression of Pressure Injuries
3. Lack of Communication with Outside Providers: Failure to Collaborate with Home Health
4. Lack of Training: Failure to Ensure Caregivers were Trained in Pressure Injury Prevention

Continuation on 809-C.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: A ALWAYS LOVING CARE HOME
FACILITY NUMBER: 315002795
VISIT DATE: 10/08/2024
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
26
27
28
29
30
31
32
In an effort to support the facility maintaining substantial compliance with health and Safety Statute and Title 22 regulations, the Department is requesting a corrective action plan from the licensee to address each of the areas of concern. The department is requesting a corrective action plan in writing by 10/29/24. The plan shall be submitted to Bethany Mirlohi and Cassandra Mikkelson.

Plan to address compliance concerns:
1. A plan to ensure every resident has a personalized care plan that addresses their risk factors for pressure injuries.
2. A plan on how you will ensure your staff are regularly observing residents’ conditions and reporting changes in a timely manner.
3. There is strong collaboration with external healthcare providers, including home health.
4. Caregivers are properly trained to prevent, monitor, and escalate concerns related to pressure injuries.

An exit interview was conducted with administrator. Copy of this report was provided to Administrator via email with request for return with signature.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2