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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002992
Report Date: 01/04/2024
Date Signed: 01/05/2024 11:35:36 AM

Document Has Been Signed on 01/05/2024 11:35 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:NELSON GREEN FAMILY HOMEFACILITY NUMBER:
315002992
ADMINISTRATOR:GREEN, LINFACILITY TYPE:
735
ADDRESS:12475 NELSON DRIVETELEPHONE:
(925) 791-8184
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 4CENSUS: 3DATE:
01/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lin GreenTIME COMPLETED:
04:30 PM
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LPA Tryon visited the facility to follow up regarding issues that were found and raised by Alta Regional Center. The following issues were noted:

- Bathrooms in the facility were worn, mold in the showers dirty walls, chipping paint, dirty toilet. On this date LPA noted that the one bathroom has just been completely rebuilt/renovated by the facility landlord and is now all new and clean. The other bathroom is still to be done, but the mold in the tub has been cleaned up, tub re-calked, toilet cleaned.

Exposed wires in the ceiling. LPA did note that there are some wires coming out of the ceiling in older bathroom and another room. Licensee explained this is where an old smoke detector system was previously installed. The wires have been capped off. They are not attractive, but are high and do not appear to be a hazard at this time.

Urine smell in bathroom. LPA did not note any odor in the bathrooms during this visit.

Missing carpet. There are a few areas in the hallways where carpets were pulled out. Apparently at the time of the Alta Visit the floors were bare, unfinished cement. However, since that visit the floors have been sealed/painted, so now have a surface and appear acceptable.

Closet doors missing. There is no Title 22 requirement for closet doors, only that there be sufficient closet space. During this visit, LPA noted that the licensee has put curtains over closet openings as per agreement with the Regional Center.

No box springs on beds. The beds were designed to be slept on without needing box springs; but this is a violation of Title 22 Regulation. Deficiency cited. The licensee went online during this visit and purchased box springs; deficiency will be cleared.
(Continued)
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: NELSON GREEN FAMILY HOME
FACILITY NUMBER: 315002992
VISIT DATE: 01/04/2024
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No cover on half a window. Licensee said that the resident had not wanted a curtain, but she does have curtains available and will put one up in that room.

- Expired food in refrigerator. LPA did not find any expired food, it has been disposed of.

- Locked food in closet in living room. This is not a violation of Title 22, since there is ample food available in the kitchen that clients can access.

- Kitchen was dirty. During LPA visit LPA found that the kitchen was clean.

- Broken drawer in kitchen. LPA noted that there appears to be a trim piece and handle missing off a kitchen drawer. However, the drawer does function and can be opened. It does not appear to be a hazard to anyone in any way. Licensee agreed to replace trim piece and handle.

- Grease stove hood. Hood has been cleaned.

- Dirty client room. There is one bedroom that is occupied by a resident who refuses to let the staff in to clean the room. Client does like to bring home items collected in the community and room is not clean. the client also chooses to sleep on the floor rather than the bed. He does have a bed and bedding there and available, and is choosing to not use it. The licensee is working with the regional center and the resident on ways to allow her in to clean the room.


The following deficiency is cited as per Title 22 regulations. Appeal rights given, exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
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Document Has Been Signed on 01/05/2024 11:35 AM - It Cannot Be Edited


Created By: Todd Tryon On 01/04/2024 at 04:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NELSON GREEN FAMILY HOME
FACILITY NUMBER: 315002992

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/04/2024
Section Cited
CCR
80098(c)(1)

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The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed,
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The licensee will ensure that all resident beds have mattress and springs as per Title 22 Regulation.
The licensee went online and purchased new box springs for all resident beds during the visit and showed receipt to LPA.
POC cleared.
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maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s). This regulation was not met as evidenced by: through observation LPA learned that the facility did not have springs on 3 of 3 resident beds.
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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
LICENSING EVALUATOR NAME:Todd Tryon
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024


LIC809 (FAS) - (06/04)
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