315002853-11-29-2023-59-AS-KMKY-CY2TVR-20231129140423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 315002853
Report Date: 11/29/2023
Date Signed: 11/29/2023 02:04:42 PM

Document Has Been Signed on 11/29/2023 02:04 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:	SIGNATURE LIVING ON CAMELIA AVENUE		FACILITY NUMBER:	315002853
ADMINISTRATOR:	OCAMPO, JESSE		FACILITY TYPE:	740
ADDRESS:	904 CAMELIA AVE		TELEPHONE:	(916) 899-5880
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95678
CAPACITY:	6	CENSUS: 6	DATE:	11/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Nerryrose Kreig		TIME COMPLETED:	02:15 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) Kevin Mknelly arrived at the facility unannounced on 11/29/23 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator arrived to assist. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. Advisories issued. The home is very clean and residents stated they are happy with care. Water temperature exceeded 125' F. LPA reviewed 6 resident files. Files are complete and well organized. Two resident files missing admission agreements and and appraisals. LPA reviewed 2 staff files. Files are complete. Advisories issued for documentation of training for restricted conditions. Licensee will submit LIC 9020, LIC 500, current facility sketch, training records for R2 (from other facility) and new Liability Insurance certificate. Deficiencies are being cited as a result of todays inspection. Exit interview conducted with licensee and copy of report left at the facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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 11/29/2023 02:04 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: SIGNATURE LIVING ON CAMELIA AVENUE	FACILITY NUMBER: 315002853
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of temperature taken, the licensee did not comply with the section cited above in 2 of 2 resident bathrooms temperature measured at 126' F which poses/posed a potential health, safety or personal rights risk, due to their ambulatory status, to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	Licensee will adjust water temperature and test log which shows 2 consecutive temperatures between 105-120' F, to CCL by the POC date of 12/6/23.

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 records review, the licensee did not comply with the section cited above in 2 out of 6 residents not have apraisals or care plans on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	Licensee will submit copies of appraisals for R5 and R6 by the POC date of 12/6/23.

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: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/29/2023 02:04 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: SIGNATURE LIVING ON CAMELIA AVENUE	FACILITY NUMBER: 315002853
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/29/2023

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 records review, the licensee did not comply with the section cited above in 2] out of 6 resident files R5 and R6 did not have admission agreements on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of admission agreements for identified residents by the POC date of 12/6/23.

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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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