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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317000496
Report Date: 08/07/2023
Date Signed: 08/07/2023 02:41:28 PM

Document Has Been Signed on 08/07/2023 02:41 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:C. SEISA HOUSE-STODDARDFACILITY NUMBER:
317000496
ADMINISTRATOR:SEISA, CUSTODIO A.FACILITY TYPE:
735
ADDRESS:317 STODDARD WAYTELEPHONE:
(530) 889-0737
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY: 6CENSUS: 4DATE:
08/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Custodio (Joel) Seisa, Licensee; and Chris Chu, AdministratorTIME COMPLETED:
12:30 PM
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On 8/7/2023 LPA Tryon and LPA Ivan Avila visited the facility to conduct an annual visit. LPAs met with licensee/Administrator Joel Seia and later with Chris Chu, Administrator..
LPAs toured the house including common areas, kitchen, bedrooms, bathrooms, hallways, staff areas, yard. The facility appears to be clean and nicely furnished. Residents have appropriate furniture, bedding, etc. Smoke detectors are installed, but LPAs found that there is no carbon monoxide detector. Fire extinguishers are present and charged.
Food supplies appear appropriate to meet requirement of 2 days perishable and 7 days non-perishable. Food appears to be varied and appetizing.
Bathrooms are clean, grab bars installed, paper towels and soap available, plumbing clean and functional.

LPAs noted that there are currently 2 residents in the home that are technically non-ambulatory due to mobility issues. There is a male resident living in a bedroom that is fire cleared as ambulatory only. Licensee states that they have told the Regional Center that the resident needs to be relocated, but so far the Regional Center has not found an alternate home.

LPAs reviewed the CARE Tool with licensee.

The following deficiencies are cited as per Title 22 regulations. Appeal Rights provided, exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2023
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 08/07/2023 02:41 PM - It Cannot Be Edited


Created By: Todd Tryon On 08/07/2023 at 12:14 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: C. SEISA HOUSE-STODDARD
FACILITY NUMBER: 317000496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as there is no carbon monoxide detector installed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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Facility will ensure that a carbon monoxide detector is installed by 8/8/2023.
Type A
Section Cited
CCR
80010(b)(1)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients. (1) Clients whose condition becomes nonambulatory shall not use rooms or areas restricted to ambulatory clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as there is one male resident who uses a wheelchair living in an ambulator only bedroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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Licensee will submit a plan of how to bring the home into compliance with the regulation to so that resident R1 lives in a non-ambulatory bedroom; or is relocated to a facility with a non-ambulatory fire clearance.
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: 08/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/07/2023 02:41 PM - It Cannot Be Edited


Created By: Todd Tryon On 08/07/2023 at 02:32 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: C. SEISA HOUSE-STODDARD
FACILITY NUMBER: 317000496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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 Ordonez
LICENSING EVALUATOR NAME:Todd Tryon
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023


LIC809 (FAS) - (06/04)
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