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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340312629
Report Date: 11/28/2023
Date Signed: 11/28/2023 02:57:15 PM


Document Has Been Signed on 11/28/2023 02:57 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:NAVARRO RESIDENTIAL CAREFACILITY NUMBER:
340312629
ADMINISTRATOR:NAVARRO, ANGELFACILITY TYPE:
740
ADDRESS:7327 SOVEREIGN COURTTELEPHONE:
(916) 502-7140
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 4DATE:
11/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator- Angel NavarroTIME COMPLETED:
01:40 PM
NARRATIVE
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LPAs Cheyenne Ratajczak, Talwinder Bains and LPM, Laura Munoz conducted a case management visit to this facility on 11/28/23 at 11:30 A.M. LPAs and LPM met with Administrator Angel Navarro and explained the purpose of today's visit.

During today's inspection, 2 clients were present. The purpose of today's visit is to follow up on several Title 17 reviews conducted at this facility by Alta California Regional Center (ACRC) between July 24, 2023, and November 7, 2023. Facility Action Reports (FARs) were generated by ACRC from the Title 17 reviews. Community Care Licensing Division (CCLD) received a copy of the FARs and it was noted in the FARs 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 FARs that apply to Title 22.

Based on the FAR reports, the facility violated the following Title 22 violations:
On 08/03/2023, it was found that staff training requirement hours were not being met. It was found that the facility was incorrectly administering medications to R1. Medication was to be given 400 mg 2x a day and facility was administering 600 mg 1x a day. Facility utilizes a Medication Administration Record (MAR). There were numerous discrepancies found on the MARs making it unclear to determine residents were getting their medications as prescribed. It was found that centrally stored medication records (CSMR) for residents were incorrect and incomplete. It was found that multiple prescribed medications for residents were not present in the facility due to the facility failing to order medications timely. It was found that the facility does not administer PRNs as prescribed.


Please continue to LIC 809C
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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


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: NAVARRO RESIDENTIAL CARE
FACILITY NUMBER: 340312629
VISIT DATE: 11/28/2023
NARRATIVE
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On 09/27/2023, Facility utilizes a Medication Administration Record (MAR). There were numerous discrepancies found on the MARs making it unclear to determine residents were getting their medications as prescribed. It was found that centrally stored medication records (CSMR) for residents were incorrect and incomplete. It was found that the facility does not administer PRNs as prescribed.

On 10/25/2023, it was found that centrally stored medication records for R1 and R2 were incorrect and incomplete. It was also found that the facility was not properly documenting medication destruction records for R2.

Based on the above, deficiencies are cited pursuant to California Code of Regulations, Title 22 and documented on the attached LIC809D.

Exit interview conducted and copy of report and appeal rights provided
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/28/2023 02:57 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: NAVARRO RESIDENTIAL CARE
FACILITY NUMBER: 340312629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/28/2023
Section Cited
CCR
80075(b)

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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not as evidenced by:
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The Licensee has satisfied the plan of correction with Alta California Regional Center. Plan of Correction is cleared during today's visit.
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Based on the FAR investigations issued by ALTA California Regional Center, the facility did not assist residents in care with medications as prescribed which posses an immediate health and safety risk to residents in care.
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Type A
11/28/2023
Section Cited
CCR80075(b)(5)(C)

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80075Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
(5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met:
(C)A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken and the client's response.
This requirement is not as evidenced by:
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The Licensee has satisfied the plan of correction with Alta California Regional Center. Plan of Correction is cleared during today's visit.
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Based on the FAR investigations issued by ALTA California Regional Center, the facility did not document and/or administer PRN medications to residents as prescribed which posses an immediate health and safety risk to residents in care.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 11/28/2023 02:57 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: NAVARRO RESIDENTIAL CARE
FACILITY NUMBER: 340312629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2023
Section Cited
CCR
80075(k)(7)

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80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications.

This requirement is not met as evidenced by:
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The Licensee has satisfied the plan of correction with Alta California Regional Center. Plan of Correction is cleared.
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Based on the FAR investigations issued by ALTA California Regional Center, the facility did not properly document and maintain centrally stored medication records as required which posses a potential health and safety risk to residents in care.
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Type B
11/28/2023
Section Cited
CCR80075(l)

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80075Health Related Services
(l) Prescription medications which are not taken with the client upon termination of services, or which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client.

This requirement is not met as evidenced by:
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The Licensee has satisfied the plan of correction with Alta California Regional Center. Plan of Correction is cleared.
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Based on the FAR investigations issued by ALTA California Regional Center, the facility did not properly document and destroy medications which posses an immediate health and safety risk to residents in care.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 11/28/2023 02:57 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: NAVARRO RESIDENTIAL CARE
FACILITY NUMBER: 340312629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2023
Section Cited
CCR
80065(f)

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80065Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
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The Licensee has satisfied the plan of correction with Alta California Regional Center. Plan of Correction is cleared.
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Based on the FAR investigations issued by ALTA California Regional Center, the licensee did not ensure staff training hours are met which posses an immediate health and safety risk to residents in care.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5