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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340314399
Report Date: 04/18/2023
Date Signed: 04/18/2023 11:54:39 AM

Document Has Been Signed on 04/18/2023 11:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DOSTY'S PRIVATE INCARE SERVICEFACILITY NUMBER:
340314399
ADMINISTRATOR:JANAE ROSSFACILITY TYPE:
735
ADDRESS:7093 CROMWELL WAYTELEPHONE:
(916) 399-1365
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 6CENSUS: 4DATE:
04/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Carolyn Ross - LicenseeTIME COMPLETED:
12:00 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 Analysts (LPA's) Ruth Wallace and Brandon Panariello conducted unannounced Required 1 Year Annual Inspection Visit. LPA's met with Administrator and explained the purpose of the visit. There are currently 4 clients.

LPA's toured the facility with Licensee. LPA's inspected the physical plant including but not limited to the common areas, kitchen, dining area, resident bedrooms; resident bathrooms, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA's observed all surface walls, baseboards, and floors need to have deep cleaning. LPA's observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms need deep cleaning around baseboards, walls, and floors. Floor vent in dining needs to be cleaned. The hot water temperature was observed to be 109.0 F degrees Fahrenheit. LPA's observed there to be a sufficient amount of perishable and non-perishable food supply on hand. LPA 'observed knives and toxins to be locked away and inaccessible to residents. Smoke and carbon detectors were in good repair. Fire extinguisher inspected 8/30/2022 and first aid kit was current. LPA's checked medication storage and found medication to be locked away and inaccessible to clients. LPA's also conducted complete care tool domain tool. The facility mitigation plan was submitted to CCLD, and it was approved on 5/7/2021.

LPA Wallace requested the following updated documents to be submitted via email by May 2, 2023: LIC 400 - Client Cash Resources, LIC 402 - Surety Bond, and LIC 610-D Emergency Disaster Plan. ruth.wallace@dss.ca.gov
Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, one deficiency was observed and cited today. Failure to correct cited deficiencies by the noted due date; civil penalties may be assessed.
Exit interview conducted with Licensee. LPA's left a copy of report and appeal rights at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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 2
Document Has Been Signed on 04/18/2023 11:54 AM - It Cannot Be Edited


Created By: Ruth Wallace On 04/18/2023 at 11:31 AM
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: DOSTY'S PRIVATE INCARE SERVICE
FACILITY NUMBER: 340314399

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation all surface walls, baseboards, and floors need a deep cleaning. The bathrooms need deep cleaning around baseboards, walls, and floors. Floor vent in dining room needs to be cleaned. The licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
1
2
3
4
Licensee agrees to deep clean all surface walls, baseboards, and floors, including bathrooms. Floor vent in dining room needs to be cleaned. All cleaning will be completed by Plan of Correction Date 5/18/2023 and pictures will be submitted via email to LPA Ruth Wallace. ruth.wallace@dss.ca.gov
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:Stephen Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


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