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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317807
Report Date: 09/21/2021
Date Signed: 09/21/2021 06:03:39 PM

Document Has Been Signed on 09/21/2021 06:03 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ALLEN'S CARE HOMEFACILITY NUMBER:
340317807
ADMINISTRATOR:ALLEN,WILLIEFACILITY TYPE:
735
ADDRESS:3701 KNIGHTLINGER STREETTELEPHONE:
(916) 922-9211
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY: 6CENSUS: 6DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Melvina Allen TIME COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 09/21/2021 at 11:19 AM. LPA Martinez met with Melvina Allen and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyard of the facility to ensure compliance with Title 22 regulations.

The current assigned administrator does not have a current administrator certificate. The licensee shall appoint an administrator that holds a current administrator certificate by 09/22/2021 The licensee shall provide LPA Martinez a copy of LIC 200, LIC 500, LIC 308, LIC 501, LIC 503, and a current administrator certificate, copies of administrator's completed education transcripts by close of business day 09/22/2021.

This facility is licensed for six residents. There are currently 6 residents who reside at this facility. LPA Martinez toured the facility with Melvina Allen on 09/21/2021 at 12:00 PM.

LPA Martinez reviewed 6 out of 6 resident files. Resident files were not up to date. Resident 1's file did not include a LIC 601 and P&I documents, and had an incomplete LIC 602. Resident 2's file did not include a LIC 601 and P&I documents and had an incomplete LIC 602 and. Resident 3' file did not include LIC 601 and P&I documents and had an incomplete 602. Resident 4's file did not did not include LIC 601 and P&I documents and had an incomplete 602. Resident 5's file did not did not include LIC 601 and P&I documents and had an incomplete 602. Moreover resident 5 did not have a discontinued medication order for Famotidine 40 MG. Resident 5's Medication Administration Record (MAR) was not filled out for the month of September 2021. LPA Martinez will return at a later date to review other resident medication files. Resident 6's file had an incomplete 602. 3 out of 3 employee files did not have a current first aid certificate. 1 out of 3 staff did not have a health screening form (LIC 503).

Continued...

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ALLEN'S CARE HOME
FACILITY NUMBER: 340317807
VISIT DATE: 09/21/2021
NARRATIVE
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The facility has one fire extinguisher, which was out of service. The fire extinguisher was last inspected in July 2020. During the visit, Melvina Allen replaced the expired fire extinguisher. The facility has exposed wires in the hallway and in the converted second common living room. The facility sketch does not reflect the current facility layout. Facility garage was converted into a second common living area for residents. Furthermore, an add on common room was added to home, which is adjacent to the converted second common living room.

The facility had an adequate supply of food. The facility water temperature was 107.2 degrees. The facility temperature was 72 degrees. The facility has a public phone. The facility has an area for activities. The smoke detectors and carbon detectors were tested and working properly. Light fixtures were tested and working in resident bedrooms. Facility Bathrooms were sanitary. The facility laundry room was sanitary. Resident bedrooms were sanitary and furnished.

The facility has submitted a mitigation plan to the department. The mitigation plan should be updated to reflect the required information on the LIC 808 document. The facility has one main entry screening area for visitors, essential visitors, and care staff. The facility has covid-19 postings throughout the facility. The facility has a 30 day supply of PPE. The facility has hand sanitizer throughout the facility.

As a result of this visit, the following deficiencies were cited, per California Code of Regulations, Title 22 and Health and Safety Code. Exit interview was conducted and a copy of the 809 report, 809D report, and appeals right were given to Melvina Allen at the end of visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/21/2021 06:03 PM - It Cannot Be Edited


Created By: Avelina Martinez On 09/21/2021 at 03:47 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ALLEN'S CARE HOME
FACILITY NUMBER: 340317807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2021
Section Cited
CCR
80020(a)

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80020 (a) Fire Clearance: All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
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 Melvina Allen replaced the fire extinguisher during the visit.
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Based on observation, interview and record review. The licensee did not ensure fire extinguisher is up to date. Fire extinguisher was last serviced in July of 2020. In addition, the fire extinguisher meter showed the fire extinguisher was not fully charged. This posed an immediate health and safety risk to residents in care.
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Type B
10/05/2021
Section Cited
CCR80087(b)(1)

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80087(b) Buildings and Grounds: All clients shall be protected against hazards within the facility through provision of the following: Protective devices including but not limited to nonslip material on rugs. This requirement is not met as evidenced by:
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Melvina stated that hole repairs and exposed wires would be fixed by poc date 10/05/2021. LPA Martinez will clear POC by facility visit.
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Based on observation and interviews old removed smoke detector location in hallway was not patched up and exposed wires were hanging from wall. Ceiling fan was removed and ceiling hole was not patched up and exposed wires were hanging from ceiling. This posed a potential health and safety risk to residents in care.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/21/2021 06:03 PM - It Cannot Be Edited


Created By: Avelina Martinez On 09/21/2021 at 04:08 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ALLEN'S CARE HOME
FACILITY NUMBER: 340317807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2021
Section Cited
CCR
80022(b)(7)(8)

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80022(b)(7)(8) Plan of Operation: The plan and related materials shall contain the following: sketch of the building(s) to be occupied, including a floor plan which describes the capacities of the buildings for the uses intended...A sketch of the grounds showing...A sketch of the grounds showing buildings ...recreation areas and other space used by the clients.

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Melvina stated she would provide an updated facility sketch and fire cleareance documentation for the room additions by POC date 10/05/2021.
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 This requirement is not met as evidenced by: Based on observation and interviews, the facility sketch did not reflect the current layout of the facility. Facility garage is converted to a common living room for residents and adjacent to this common living room is an activities room for resident use, which is an add on to the facility. This posed a potential risk to resident in care.
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Type B
10/26/2021
Section Cited
CCR80070(a)

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80070 Client Records The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
This requirement is not met as evidenced by:
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Melvina stated she would reorganize client records and complete and submit missing documents to CCLD by 10/12/2021. Provide record training to staff by POC date 10/26/2021. Melvina agrees to email LPA training materials by POC 10/26/2021
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Based on observation, record review, and interviews, the licensee did not ensure 6 out of 6 resident files were up to date. This posed a potential risk to resident in care.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/21/2021 06:03 PM - It Cannot Be Edited


Created By: Avelina Martinez On 09/21/2021 at 04:26 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ALLEN'S CARE HOME
FACILITY NUMBER: 340317807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2021
Section Cited
CCR
80066(a)(10)(11)

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Personnel Records 80066(a)(10)(11) The licensee shall ensure that personnel records are maintained. A health screening ...Tuberculosis test documents... This requirement was not met as evidence by:
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Melvina stated staff 2 will be receiving a health screening on 09/22/2021. Health screening form will be emailed to LPA Martinez by 09/27/2021. Provide personnel record training to staff by POC date 10/26/2021. Melvina agrees to email LPA training materials by POC date 10/26/2021
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Based on record review, interview, and observation Staff 2 did not have a health screening form. This posed a potential health and safety risk to residents in care.
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Type B
10/05/2021
Section Cited
CCR80075(f)

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80075(f) Health Related Services Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement was not met as evidence by:
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Melvina stated staff will receive first aid training by POC date 10/05/2021. Melvina will email LPA Martinez CPR documentation on POC date 10/05/2021.
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Based on observation and file review the licensee did not ensure 3 out 3 staff had a current first aid certificate. This posed a potential health and safety risk to residents in care.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 09/21/2021 06:03 PM - It Cannot Be Edited


Created By: Avelina Martinez On 09/21/2021 at 05:04 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ALLEN'S CARE HOME
FACILITY NUMBER: 340317807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2021
Section Cited
CCR
80064(b)

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85064 (b) Administrator Qualifications and Duties: All adult residential facilities shall have a certified administrator. This requirement was not met as evidence by: Based on observation and record review, this facility's administrator does not have a current administrator certificate.
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Melvina agreed to appoint a temporary adminstrator by POC date 09/22/2021. Melvina agreed to review 85064 Administrator Qualifications and Duties regulations by POC date 10/12/2021. Melvina agreed to email LPA Martinez a written statement that she reviewed 85064 Administrator Qualifications and Duties regulations by 10/12/2021.
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This posed a potential health and safety risk to residents in care.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021


LIC809 (FAS) - (06/04)
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