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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
315920021
Report Date:
09/25/2024
Date Signed:
09/26/2024 03:18:11 PM
Document Has Been Signed on
09/26/2024 03:18 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:
CHERRY RIDGE VILLA
FACILITY NUMBER:
315920021
ADMINISTRATOR:
KAUR, NIRMALJEET
FACILITY TYPE:
740
ADDRESS:
6893 CHERRY RIDGE CIR.
TELEPHONE:
(916) 786-0654
CITY:
ROSEVILLE
STATE:
CA
ZIP CODE:
95678
CAPACITY:
6
CENSUS:
6
DATE:
09/25/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
02:00 PM
MET WITH:
caregiver
TIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 11/7/23 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. Designee, Jerson Quezon, arrived to assist.
LPA discussed that if Licensee wishes to designate a new Administrator they are to contact CCL to update facility records.
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 health, safety deficiencies were observed. Residents appeared to have their care needs met.
LPA reviewed 6 resident files. Files are lacking some necessary records.
LPA reviewed 3 staff files. Files are lacking some training records.
Deficiencies are being cited at this time.
Do to a shortage of time and technical computer issues, LPA will return to complete the inspection.
Exit interview conducted with licensee and copy of report left at the facility and appeal rights provided.
SUPERVISOR'S NAME:
Maribeth Senty
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Kevin Mknelly
TELEPHONE:
(209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE:
09/25/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/25/2024
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
5
Document Has Been Signed on
09/26/2024 03:18 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:
CHERRY RIDGE VILLA
FACILITY NUMBER:
315920021
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(d)
Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in S3 is a live in staff residing a room not designed for staff occupency which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/10/2024
Plan of Correction
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2
3
4
Licensee will establish appropriate accomodations for staff or have not have staff live in by the POC date of 10/10/24.
be cleared by visit.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
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 S2 did not have required training prior ro working with residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/03/2024
Plan of Correction
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2
3
4
R2 staff is to be completed and supervised until completed. Proof of training to be submitted by 10/3/24.
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 Senty
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Kevin Mknelly
TELEPHONE:
(209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE:
09/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/26/2024
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
09/26/2024 03:18 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:
CHERRY RIDGE VILLA
FACILITY NUMBER:
315920021
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(d)(1)
Other Provisions
(1) A licensed or certified health professional with valid certification shall receive eight hours of training on resident characteristics, resident records, and facility practices and procedures prior to providing direct care to residents.
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 [count] out of 1 of 3 , S1 , staff files reviewed found insufficient training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/17/2024
Plan of Correction
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2
3
4
Licensee to submit proof of completed staff traing for S1 by the POC date of 10/17/24
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based onresident records, the licensee did not comply with the section cited above in 2 of 6 residents, R1 and R3, have dementia diagnosis with assessments greater that 12 months old which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/24/2024
Plan of Correction
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2
3
4
Licensee will submit up to date LIC 602s for R1 and R3 by 10/24/24
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 Senty
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Kevin Mknelly
TELEPHONE:
(209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE:
09/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/26/2024
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
09/26/2024 03:18 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:
CHERRY RIDGE VILLA
FACILITY NUMBER:
315920021
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)(3)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions.
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 1 of 6 residents, R6, did not have a completed pre-appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/24/2024
Plan of Correction
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2
3
4
Licensee will submit a plan for who will be assigned to ensure pre-appraisals are completed
and LIC 625s will be submitted by 10/24/24.
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:
09/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/26/2024
LIC809
(FAS) - (06/04)
Page:
4
of
5
Document Has Been Signed on
09/26/2024 03:18 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:
CHERRY RIDGE VILLA
FACILITY NUMBER:
315920021
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/25/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above in the smoke detector in the living room was non-operational for approximately several days without repair which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/27/2024
Plan of Correction
1
2
3
4
Licesee contacted the fire department who will inspect and advise repair.
Licensee will submit the recommended plan to correct by 9/27/24. proof of completion will be submitted when done as recommended.
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:
09/26/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/26/2024
LIC809
(FAS) - (06/04)
Page:
5
of
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