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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317735
Report Date: 01/09/2024
Date Signed: 01/09/2024 04:39:57 PM


Document Has Been Signed on 01/09/2024 04:39 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:TAYLOR HOME II, THEFACILITY NUMBER:
340317735
ADMINISTRATOR:FILOMENA TAYLORFACILITY TYPE:
740
ADDRESS:3609 PLYMOUTH DRIVETELEPHONE:
(916) 348-8451
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY:6CENSUS: 2DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Administrator- Filomena Taylor TIME COMPLETED:
04:45 PM
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On 01/09/24, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced at the facility to conduct a Required 1- year annual inspection utilizing the care tool. LPA met with Administrator, Filomena Taylor and explained the purpose of the visit.

LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: three (3)residents room, two (2) bathroom, kitchen, backyard, storage area, and the common areas. LPA observed one resident in the common area watching television and one resident in their room. LPA observed the facility to have 2+ days of perishable and 7+ days of nonperishable foods. LPA observed toxins and knives to be locked and inaccessible to residents in care. LPA also observed centrally stored medications are kept locked and inaccessible to residents.

Hot water temperature was measured at 106 degrees Fahrenheit in kitchen sink, which is within the required range of 105 to 120 degrees. Smoke detectors are current and in compliance with fire safety including carbon monoxide detector. Fire extinguisher and first aid kit are maintained and ready for emergency use.

LPA conducted a file review of personnel and residents records. LPA observed one staff file to be incomplete with the required documents. LPA provided facility with a copy of LIC311F, which states what is needed for the resident, personnel, administrative and dementia care records

LPA completed the full care tool and deficiencies was observed. Please see LIC 809-D.



Exit interview conducted and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
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 01/09/2024 04:39 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: TAYLOR HOME II, THE
FACILITY NUMBER: 340317735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

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 file review and interview, the licensee did not comply with the section cited above in 1 out of 1 personnel files were observed to have no annual trainings, which posed a potential health, safety or personal rights risk to persons in care.

POC Due Date: 01/23/2024
Plan of Correction
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Licensee will submit a statement of understanding that all staff needs annual 20 hours of training. Submit statement to LPA Ratajczak by 01/23/2024.
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: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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