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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317275
Report Date: 07/12/2023
Date Signed: 07/12/2023 12:25:11 PM


Document Has Been Signed on 07/12/2023 12:25 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:DAY AND NIGHT FACILITIES CAREFACILITY NUMBER:
340317275
ADMINISTRATOR:BUTUZA, JOHN A.FACILITY TYPE:
740
ADDRESS:7430 WELLS AVENUETELEPHONE:
(916) 965-3412
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 1DATE:
07/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:John Butuza, Administrator TIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada and AGPA Ahmad Rashid, arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the full inspection care tool. Department staff met with John Butuza, Administrator and Maria Butuza, staff. LPA observed (1) resident present and sitting in the kitchen area. Currently, there is (1) resident. and there are no residents on hospice.

LPA and Administrator toured the interior and exterior of the facility including the common areas, (6) private resident bedrooms, (3) resident bathrooms, staff room, kitchen, laundry and garage. LPA observed the facility to be clean, in good repair and odor-free. LPA observed each bathroom to have the necessary grab bars, non-skid flooring, paper towels, trash can with lid and 20-second hand-washing poster. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food in the kitchen. Medications are locked in a designated closet, and all toxins are locked in the laundry area. There are no sharps used. LPA observed sufficient PPE/incontinent supplies and linens/towels/blankets. The inside temperature measured 74*F and the hot water measured 120*F. The fire extinguisher was last serviced 3/23/23. One smoke and monoxide alarm was tested and found to be working correctly. Facility conducts quarterly emergency drills. The driveway area is open and unlocked and can be used for emergency exit. There is outside seating on the front porch. LPA and Administrator reviewed ordered medications to those being administered for (1) resident and found no discrepancies. Administrator to obtain an updated medication list to include any medications that have been discontinued. LPA reviewed (2) staff files and found them to contain current First Aid/CPR certification-both staff are fingerprint cleared; however, staff (S1) did not have all required annual training. RCFE Administrator certificate #6016326740- exp 6/3/24. All required postings were observed. Emergency Disaster Plan and Infection Control Plan to be updated and available for staff in binders. An updated copy of liability insurance was obtained (exp 6/24). LPA requested an updated copy of LIC308 and LIC500 be sent to the Department by 7/19/23. Per California Code of Regulations, Title 22, the following (2) deficiencies are being issued on the 9099-D page. Also a Technical Advisory Note is issued. Exit interview. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
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 07/12/2023 12:25 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: DAY AND NIGHT FACILITIES CARE
FACILITY NUMBER: 340317275

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on ecord review, the licensee did not comply with the section cited above in 1 out of 2 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2023
Plan of Correction
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Licensee/Administrator agrees to have staff, S1, complete the required (20) hours of ongoing training as required per the HSC and submit documentation that the training has been completed to CCLD by fax/email by 8/8/23. LPA observed that S1 had completed (20) hours of medication training on 8/8/22 and had completed First Aid/CPR in Jan 2023 (exp Jan 2025).
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in (1) out of (1) residents, which poses/posed a potential health, safety or personal rights risk to persons in care. Care Plan for resident (R1) was last updated in January 2020.
POC Due Date: 08/09/2023
Plan of Correction
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Licensee/Administrator agrees to complete and submit an updated care plan (LIC625) to CCLD by 8/8/23.
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
LIC809 (FAS) - (06/04)
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