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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 01:31:58 PM


Document Has Been Signed on 11/28/2023 01:31 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator, Navarro Angel TIME COMPLETED:
01:45 PM
NARRATIVE
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On 11/28/23, Licensing Program Manager (LPM ) Laura Munoz and Licensing Program Analysts (LPAs) Talwinder Bains and Cheyenne Ratajczak arrived at the facility to conduct unannounced annual facility inspection and met with Administrator, Navarro Angel and explained the purpose of today's visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed residents (2) and staff files (2). All residents files contained the required paperwork except for Consent Form (LIC627C) and Personal Rights form (LIC613). Staff file contained the required paperwork. Staff have current first aid and CPR training. All required postings were observed. LPAs reviewed medications of 2 residents comparing with physician orders and find no errors.

LPAs and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included residents rooms, bathrooms, kitchen, common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. All exits were unobstructed. The administrator's certificate is current. LPAs checked the kitchen area for the ability to prepare and store food. LPAs observed the area used for medication to be locked and inaccessible to residents. LPAs observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use . Water temperature is within compliance (110 degree F) .Inside temperature was observed to be 70 degree F. During inspection, LPAs observed cleaning chemicals in garage, gasoline container and sharp gardening tools in the backyard area which were accessible to residents in care.

LPAs requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by 12/15/23.

Deficiencies are cited per Title 22 regulations during today's visit. See LIC809D for details.
Exit interview conducted. A copy of this report and appeal rights were printed and given to Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
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 3


Document Has Been Signed on 11/28/2023 01:31 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observation, the licensee did not comply with the section cited above as cleaning chemicals were left open in garage and gasoline container and sharp gardening tools were left open and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2023
Plan of Correction
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Licensee shall submit statement of understanding of regulation 87309(a) and will do training with staff .
All documents sholud be sent to department by POC date-11/29/23.
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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
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: 2 of 3


Document Has Been Signed on 11/28/2023 01:31 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, facility did not have Consent Form (LIC627C) and Personal Rights form (LIC613) for 2 out 2 residents files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2023
Plan of Correction
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Licensee shall complete Consent Form (LIC627C) and Personal Rights form (LIC613) for all residents files and submit proof to department by POC date-12/12/23.
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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
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 3