315002992-7-31-2025-59-AS-TTRN-DK4V9A-20250731161402

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 315002992
Report Date: 07/31/2025
Date Signed: 07/31/2025 04:14:17 PM

Document Has Been Signed on 07/31/2025 04:14 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:	NELSON GREEN FAMILY HOME		FACILITY NUMBER:	315002992
ADMINISTRATOR/ DIRECTOR:	GREEN, LIN		FACILITY TYPE:	735
ADDRESS:	12475 NELSON DRIVE		TELEPHONE:	(925) 791-8184
CITY:	AUBURN	STATE: CA	ZIP CODE:	95603
CAPACITY: 4		CENSUS: 4	DATE:	07/31/2025
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Lin Green, Licensee		TIME VISIT/ INSPECTION COMPLETED:	04:30 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 7/31/2025 LPA Tryon visited the facility to do case management visit. The purpose of the visit was to follow up on a facility Title 17 Inspection conducted by Alta California Regional Center July 15, 2025. Alta workers had issued a Facility Action Report. There were two major areas that were included in the FAR: - Personnel Files - Medications LPA reviewed personnel files with Ms. Green. At this time, the facility has been able to obtain the majority of forms that were noted in the report; and in the case of one staff, the staff has been taken off the schedule until documentation is obtained. In reviewing files, LPA ascertained that all documents are present at this time with the exception of an updated TB clearance for staff Marcella Green. The Administrator will follow through with obtaining this documentation. Alta staff had noted that the TB Clearance/Health Screening was missing for licensee. However, in reviewing the facility records, It was found that Ms. Green did have a Health Screening/TB clearance from the original application for the license, which meets the requirement. Regarding Medications, it was noted that a Medication Transfer Sheet for resident R1 was dated for November; but the resident actually went on a family visit in December. LPA learned that the family had dated the form for November, when the visit was actually in December. There was disagreement between forms regarding a medication for R1. This was an issue of resident wanting the medication at night, when the prescription was written for morning. The home had asked the pharmacy to change the time. It had changed, but somehow got changed back, causing the appearance of an issue with dosing. There was also noted to be a "transfer sheet" missing for a visit in July; LPA noted that it had been signed and dated.

NAME OF LICENSING PROGRAM MANAGER: Troy Ordonez
NAME OF LICENSING PROGRAM ANALYST: Todd Tryon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

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 3

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 3

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: NELSON GREEN FAMILY HOME	FACILITY NUMBER: 315002992
	VISIT DATE: 07/31/2025

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

(cont).
There were reportedly missing entries for a supplement and PRN medication. The PRN has been discontinued at this time.

For resident R2, Medications had reportedly been pre-dispensed for residents into a plain container. The facility has disposed of this system, and is now dispensing medications directly from the pharmacy containers/envelopes to the residents at each medication administration.

There was an issue regarding numbers of a medication given not matching between the MAR and the medication container. Apparently a house supply had been used on a few occasions, causing the numbers to not match. We discussed the importance of medications coming from residents' individual supplies, rather than a house supply.

There was confusion about the numbers of another medication; it appears that this was a misunderstanding of the numbers and how they were dispensed. Medication appears to be dispensed appropriately.

Another medication appeared to have the wrong dose for a medication in the supply. This appears to have arisen from a possible error in writing down instructions from staff of the previous licensee, and has been resolved.

The home appears to be following up appropriately with the issues noted on the FAR. The home is obtaining an updated physical and TB clearance for Marcella Green and CPR/First Aid.

NAME OF LICENSING PROGRAM MANAGER: Troy Ordonez
NAME OF LICENSING PROGRAM ANALYST: Todd Tryon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3