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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317187
Report Date: 04/15/2022
Date Signed: 04/15/2022 03:11:33 PM

Document Has Been Signed on 04/15/2022 03:11 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:G.M. ROJO GUEST HOMEFACILITY NUMBER:
340317187
ADMINISTRATOR:ROJO, MADELYN M.FACILITY TYPE:
740
ADDRESS:5637 WHITE FIR WAYTELEPHONE:
(916) 344-8072
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY: 6CENSUS: 6DATE:
04/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Madelyn M Rojo, AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood met with Administrator, Madelyn Rojo, to conduct a case management visit. The purpose of today's visit is to follow up on a Title 17 review conducted at this facility by Alta California Regional Center (ACRC) on 03/28/22. A Facility Action Report (FAR) was generated by ACRC from the Title 17 review. CCLD received a copy of the FAR and it was noted that the facility was cited for violations that are in both Title 17 and Title 22. CCLD's 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:
Based in ACRC's inspection, centrally stored medication documents did not accurately reflect the quantity and expiration date for multivitamins.

As a result of today's inspection, a deficiency is cited pursuant to California Code of Regulations, Title 22, Section 87465(h)(6) regarding centrally stored medication documents. Deficiencies are listed on 809-D.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. The Administrator’s signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2022
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 04/15/2022 03:11 PM - It Cannot Be Edited


Created By: Michael Hood On 04/15/2022 at 01:38 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: G.M. ROJO GUEST HOME
FACILITY NUMBER: 340317187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2022
Section Cited
CCR
87465(h)(6)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year. This requirement is not met as evidence by:
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Administrator will create a written plan to ensure medications are logged into the Centrally Stored Medication Log correctly. Administrator will also schedule on-the-job training for April, May, and June 2022 regarding medication documentation.
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Based on FAR received by ACRC regarding inspection conducted on 3/28/2022, facility did not ensure that centrally stored medication documents were accurate, which poses an immediate health, safety, and personal rights risk to the residents in care.
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Facility will submit to LPA information regarding training, including time and date of training and training material, by POC due date of 4/16/22.

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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:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022


LIC809 (FAS) - (06/04)
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