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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315003007
Report Date: 02/16/2024
Date Signed: 02/16/2024 01:34:54 PM


Document Has Been Signed on 02/16/2024 01:34 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:DAD'S PLACE INCFACILITY NUMBER:
315003007
ADMINISTRATOR:MURRAY, KATHERINE SFACILITY TYPE:
740
ADDRESS:1220 LIVE OAK LANETELEPHONE:
(530) 718-0932
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 5DATE:
02/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Christina Brown, House ManagerTIME COMPLETED:
01:30 PM
NARRATIVE
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On 2/16/2024 LPA visited the facility to perform the annual visit. LPA met with House Manager Christina Brown. The facility currently has 5 residents living at the facility. There is currently 1 resident using hospice services.

LPA toured the facility including common areas, kitchen, food supplies, resident rooms, bathrooms, hallways, office area, back yard, laundry.
The facility was clean and well-furnished. Resident rooms were appropriately furnished with required furniture. Food supplies were adequate to meet the requirement of 2 days perishable food and 7 days non-perishable. Medications were centrally stored and locked, centrally stored logs maintained. Knives and other sharp items locked, as well as cleaners and other potentially hazardous items. Smoke detectors and carbon monoxide detectors installed and functioning. Fire extinguisher present and charged. The facility has an ongoing activity calendar and various games and supplies. Hot water within appropriate temperature range.

LPA reviewed 2 of 5 resident files; and 5 staff files. Files include required documents. LPA found that one staff, S1, did not have a physical exam/TB test in the file. Administrator certificate present and current. Staff have completed 1st aid/CPR training, as well as other required training.

LPA reviewed and completed the CARE Tool with House Manager. LPA interview one staff and 2 residents.

The following deficiency was noted as per Title 22 regulations. Exit interview completed, Appeal Rights provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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 02/16/2024 01:34 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: DAD'S PLACE INC

FACILITY NUMBER: 315003007

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(12)
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: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 5 personnel records reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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The facility will ensure that all staff files are kept complete and current. The licensee will ensure that staff S1 has a physical exam/TB test and form completed. Completed form will be submitted to CCL by 3/15/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
LIC809 (FAS) - (06/04)
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