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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
315002812
Report Date:
11/28/2022
Date Signed:
11/28/2022 03:59:31 PM
Document Has Been Signed on
11/28/2022 03:59 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
CHICO - RESIDENTIAL
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER:
315002812
ADMINISTRATOR:
ARGANA, FERDINAND
FACILITY TYPE:
740
ADDRESS:
4100 SHORTHORN WAY
TELEPHONE:
(209) 834-4040
CITY:
ROSEVILLE
STATE:
CA
ZIP CODE:
95747
CAPACITY:
6
CENSUS:
6
DATE:
11/28/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
02:10 PM
MET WITH:
Lucy Bustamante and Susan Westbrook
TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) K. Hiratsuka, arrived at the facility unannounced to conduct an annual visit. LPA wore a surgical mask during visit. LPA observed caregivers wearing surgical masks during visit and LPA was screened at the entrance by the caregivers.
This facility has four resident rooms; two shared and two private. None of the rooms have exits to the outside. There is no staff room so the facility shall have 24 hour awake night staff. The main entrance opens into the hallway that has the resident rooms and locked laundry room. Directly to the left is a door that leads to the garage. To the right is a short hallway that leads to one shared room, one private room, and a full common bathroom that has a shower with nonskid floor and appropriate grab bars. On the right past the door leading to the garage is a private resident room with a full private bathroom. Past the short hallway on the right of the main entrance is another short hallway that leads to the right and the final shared resident room with a full private bathroom. The kitchen, dining, and main common area is located in the back of the facility. There is a sliding glass door leading to the outside. The kitchen has a locked cabinet for sharp knives. Laundry room has a locked cabinet for medications and small refrigerator for medications. There are gates on both sides of the facility.
Today LPA inspected staff and resident files
Today, LPA observed the following deficiencies:
-no staff training logs for required training for caregivers including medication training. Caregivers explained to LPA the training they received for medications, but there is no training log. There is no training logs for activities of daily living, personal rights, dementia, hospice, and other subjects required.
SUPERVISOR'S NAME:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
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of
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER:
315002812
VISIT DATE:
11/28/2022
NARRATIVE
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-Resident records are missing pre-appraisals and written plans of care
-all residents are missing personal inventory lists
-four of six resident records are missing emergency contact ID
-two of six have physician's reports older than 12 months and the residents have a diagnosis of dementia
Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties.
appeals rights left
SUPERVISOR'S NAME:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2022
LIC809
(FAS) - (06/04)
Page:
2
of
11
Document Has Been Signed on
11/28/2022 03:59 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
CHICO - RESIDENTIAL
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER:
315002812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/28/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87218(a)(1)
Theft and Loss
(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (1) The initial personal property inventory shall be completed by the licensee and the resident or the resident's representative.
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 six out of six resident files are missing the inventory list which poses a potential personal rights risk to persons in care.
POC Due Date:
12/28/2022
Plan of Correction
1
2
3
4
Licensee shall submit a written plan of correction on how they shall ensure all resident inventory lists shall be completed. If a resident refuses, then the licensee shall have in writing the resident refused to have inventory done.
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
This was cited in error. NO deficiency
POC Due Date:
12/28/2022
Plan of Correction
1
2
3
4
This was cited in error. No deficiency
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:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2022
LIC809
(FAS) - (06/04)
Page:
3
of
11
Document Has Been Signed on
11/28/2022 03:59 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
CHICO - RESIDENTIAL
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER:
315002812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/28/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
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:
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 the staff records are incomplete. They are missing training logs, and criminal record statements, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/28/2022
Plan of Correction
1
2
3
4
Licensee shall submit in writing how they shall ensure all staff files are complete.
Type B
Section Cited
CCR
87412(a)(6)(A)
Personnel Records
(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g).
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 there are no staff training logs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/28/2022
Plan of Correction
1
2
3
4
Licensee shall submit in writing how they shall ensure there are complete staff training logs.
LPA did observed staff worked at a previous residential care facility for the elderly prior to this facility.
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:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2022
LIC809
(FAS) - (06/04)
Page:
4
of
11
Document Has Been Signed on
11/28/2022 03:59 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
CHICO - RESIDENTIAL
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER:
315002812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/28/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(13)(A)
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: (A) A signed statement regarding their criminal record history as required by Section 87355(d).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
cited in error. All staff have criminal record clearance
POC Due Date:
11/28/2022
Plan of Correction
1
2
3
4
cited in error. NO deficiency cited.
Type B
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:
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 because there is no proof of staff training which poses/posed a potential health, safety or personal rights risk to persons in care.
LPA did observed staff worked at a previous residential care facility for the elderly prior to this facility.
POC Due Date:
12/28/2022
Plan of Correction
1
2
3
4
Licensee shall submit in writing how they shall ensure all staff are full trained per the regulations and how they are going to have a staff training log.
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:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2022
LIC809
(FAS) - (06/04)
Page:
5
of
11
Document Has Been Signed on
11/28/2022 03:59 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
CHICO - RESIDENTIAL
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER:
315002812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/28/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(2)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the license did not comply with the section cited above because the personnel records lack verification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/28/2022
Plan of Correction
1
2
3
4
Licensee shall submit in writing how they are going to ensure there is verification.
LPA did observed staff worked at a previous residential care facility for the elderly prior to this facility.
Type B
Section Cited
CCR
87613(a)(2)(B)
General Requirements for Restricted Health Conditions
(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (B) Training shall be completed prior to the staff providing services to the resident.
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 because there is no proof staff received the training and by whom which poses/posed a potential health, safety or personal rights risk to persons in care.
LPA did observed staff worked at a previous residential care facility for the elderly prior to this facility.
POC Due Date:
12/28/2022
Plan of Correction
1
2
3
4
Licensee shall submit in writing how they shall ensure the person giving the staff training is quailified and how they shall ensure the trainer is qualified.
LPA did observed staff worked at a previous residential care facility for the elderly prior to this facility.
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:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2022
LIC809
(FAS) - (06/04)
Page:
6
of
11
Document Has Been Signed on
11/28/2022 03:59 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
CHICO - RESIDENTIAL
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER:
315002812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/28/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on 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 because there are no staff training logs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/28/2022
Plan of Correction
1
2
3
4
Licensee shall submit in writing how they shall ensure all staff are trained per the regulations and how they are going to maintain verification of the training.
LPA did observed staff worked at a previous residential care facility for the elderly prior to this facility.
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:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2022
LIC809
(FAS) - (06/04)
Page:
7
of
11
Document Has Been Signed on
11/28/2022 03:59 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
CHICO - RESIDENTIAL
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER:
315002812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/28/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.
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 because there is no proof of staff training which poses/posed a potential health, safety or personal rights risk to persons in care. Caregiver did describe to LPA the process of the training the licensee gave her regarding medication
POC Due Date:
12/28/2022
Plan of Correction
1
2
3
4
Licensee shall submit in writing how they shall ensure all staff have the required medication training and how they shall verify the training.
LPA did observed staff worked at a previous residential care facility for the elderly prior to this facility.
Type B
Section Cited
HSC
1569.69(a)(3)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (3) An employee shall be required to complete the training requirements for hands-on shadowing training described in this subdivision prior to assisting any resident in the self-administration of medications. The training and instruction described in this subdivision shall be completed, in their entirety, within the first two weeks of employment.
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 because there is no proof of staff training which poses/posed a potential health, safety or personal rights risk to persons in care. Caregiver did describe to LPA the process of the training the licensee gave her regarding medication
POC Due Date:
12/28/2022
Plan of Correction
1
2
3
4
Licensee shall submit in writing how they shall ensure all staff have the required medication training and how they shall verify the training.
LPA did observed staff worked at a previous residential care facility for the elderly prior to this facility.
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:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2022
LIC809
(FAS) - (06/04)
Page:
8
of
11
Document Has Been Signed on
11/28/2022 03:59 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
CHICO - RESIDENTIAL
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER:
315002812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/28/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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 the resident files are incompletewhich poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/28/2022
Plan of Correction
1
2
3
4
Licensee shall submit in writing how they shall ensure resident files are complete
Type B
Section Cited
CCR
87506(b)(9)
Resident Records
(b) Each resident's record shall contain at least the following information: (9) Name, address and telephone number of physician and dentist to be called in an emergency.
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 residents are missing emergency contact information which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/28/2022
Plan of Correction
1
2
3
4
Licensee shall submit in writing how they shall ensure resident files are complete
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:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2022
LIC809
(FAS) - (06/04)
Page:
9
of
11
Document Has Been Signed on
11/28/2022 03:59 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
CHICO - RESIDENTIAL
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER:
315002812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/28/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(16)
Resident Records
(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
cited in error. NO deficiency
POC Due Date:
11/28/2022
Plan of Correction
1
2
3
4
cited in error. NO deficiency
Type B
Section Cited
CCR
87456(a)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8:
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 based on none of the residents having pre-appraisals in the file poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/28/2022
Plan of Correction
1
2
3
4
Licensee shall submit in writing how they shall ensure all residents have pre-appraisals done prior to being admitted.
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:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2022
LIC809
(FAS) - (06/04)
Page:
10
of
11
Document Has Been Signed on
11/28/2022 03:59 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
CHICO - RESIDENTIAL
,
520 COHASSET RD., STE. 170
CHICO
,
CA
95926
FACILITY NAME:
BLESSED HOMECARE 2 ROSEVILLE
FACILITY NUMBER:
315002812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/28/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.
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 because none of the residents have written pre-appraisals which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/28/2022
Plan of Correction
1
2
3
4
Licensee shall submit in writing how they shall ensure all residents have pre-appraisals done prior to being admitted.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
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 none of the residents have individual service needs plans which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
12/28/2022
Plan of Correction
1
2
3
4
Licensee shall submit in writing how they shall ensure all residents have individual service plans.
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:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
11/28/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/28/2022
LIC809
(FAS) - (06/04)
Page:
11
of
11