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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002860
Report Date: 01/09/2024
Date Signed: 01/10/2024 08:46:59 AM


Document Has Been Signed on 01/10/2024 08:46 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:JOY'S CARE HOME 2FACILITY NUMBER:
315002860
ADMINISTRATOR:SUSBILLA, GLORIA JOYCE BROFACILITY TYPE:
740
ADDRESS:1229 KASEBERG CIRCLETELEPHONE:
(916) 297-5675
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 3DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Calvin Bon SusbillaTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 1/9/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with a caregiver and explained the purpose of the visit. Licensee and Admin was present.

LPA and caregiver 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, kitchen and dining. In the areas toured no immediate health, safety, or personal rights violations were observed.
LPA advised that the rear exit hallway staff area be cleared and that hot water be monitored regularly as temperature was measure at 120' F.

LPA reviewed resident files. R1 has an incomplete appraisal. R1 needs a diabetes care plan and staff training. R3 Needs a PRN authorization order.
Staff files were reviewed. 1 of 3 staff do not have required training on file. S3 does not have proof of 2023 training on file.

LPA requested liability insurance certificate (certificate to be submitted by 11/27/23).

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
Exit interview conducted. Report copy and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
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 01/10/2024 08:46 AM - 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: JOY'S CARE HOME 2
FACILITY NUMBER: 315002860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 food passed use by date in the pantry and bagged on the counter which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2024
Plan of Correction
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Licensee will submit a statement that all expired food has been removed from the facility as well as a food storage/ monitoring plan by the POC date of 1/23/24.
Type B
Section Cited
CCR
87555(b)(7)
General Food Service Requirements
(b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and observation, the licensee did not comply with the section cited above in 1 of 3 resident diets which found R1's preferred sugar substitute is not available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2024
Plan of Correction
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Licensee will submit a diabetes care plan for R1 to include, sample menu, R1's food preferences and staff training on diabetes by the POC date of 1/23/24.
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 SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2