<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317003807
Report Date: 07/18/2024
Date Signed: 07/18/2024 03:16:02 PM

Document Has Been Signed on 07/18/2024 03:16 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:BADETTE'S PLACE INC.FACILITY NUMBER:
317003807
ADMINISTRATOR/
DIRECTOR:		CARRILLO, BLESFACILITY TYPE:
735
ADDRESS:9455 DUFFY LANETELEPHONE:
(916) 773-1925
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 4CENSUS: 4DATE:
07/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Bles Barrillo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 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
Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management visit. LPA met with Administrator Bles Barrillo during today's inspection. Currently there are 4 clients residing at the home.

Community Care Licensing Division (CCLD) received a copy of the FAR and it was noted in the FAR the facility was cited for violations that are in both Title 17 and Title 22. The visit today is to address the issues found in the FAR that apply to Title 22.

Based on the FAR report, the facility violated the following Title 22 violations:
1. Upon a review of Client medications, it was found client had expired mineral oil medication that were being administered.

Based on the above, deficiencies are cited pursuant to California Code of Regulations, Title 22 and documented on the attached LIC809-D.

Exit interview conducted and copy of report and appeal rights provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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 2
Document Has Been Signed on 07/18/2024 03:16 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 07/18/2024 at 03:06 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
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: BADETTE'S PLACE INC.
FACILITY NUMBER: 317003807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2024
Section Cited
CCR
80075(b)

1
2
3
4
5
6
7
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
1
2
3
4
5
6
7
Administrator has disposed of expired medication and purchased a new bottle of mineral oil medication. Administrator to submit into CCL a plan of how they will ensure expired medications will not be
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on medication review the licensee did not provide proper medication the client in care which posed a potential risk to residents in care.
8
9
10
11
12
13
14
administered to clients in care. Plan to be sent into CCL by 7/26/24.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2