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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317817
Report Date: 11/14/2023
Date Signed: 11/14/2023 02:16:14 PM


Document Has Been Signed on 11/14/2023 02:16 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CLEGG CARE FACILITYFACILITY NUMBER:
340317817
ADMINISTRATOR:CLEGG, EDNA SFACILITY TYPE:
740
ADDRESS:7249 CARMI STREETTELEPHONE:
(916) 429-6444
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:10CENSUS: DATE:
11/14/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Edna Clegg and Maxwell LlorenteTIME COMPLETED:
02:30 PM
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A Non-Compliance Conference (NCC) was conducted on this day, 11/14/2023, by the Sacramento South Regional Office via office visit. The purpose of this Non-Compliance Conference meeting was to follow up with the facility after an initial NCC was held on 11/02/2023. Due to facility technology issues the NCC meeting was rescheduled for today. Present in the meeting was Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Lisa Rios, Licensing Program Analyst (LPA) Pang Lee. Facility representatives present include Licensee, Edna Clegg, and Caregiver/House Manager, Maxwell Llorente.

During this virtual meeting, the Non-Compliance Conference process was explained to the Licensees. A Non-Compliance Conference Summary (LIC 9111) was generated to document this office meeting. A copy of this report and LIC 9111 was provided to the licensee. The facility has previously received 4 Type A citations and 9 Type B citations since 01/14/2020.



Issues discussed during the meeting were:

· The citation regarding resident's rights due to neglect resident sustained a shoulder dislocation.
· Following plan of operations
· Evictions procedure: 30 days eviction notice if facility can no longer meet resident's need.
· Personal Rights (locked kitchen/pantry and confiscated residents' snacks and tool set)
· Fire Clearance (carbon monoxide detector not in good repair)
· Maintenance and Operation (hot water measured at 150 *F)
· Incidental Medical and Dental Care Services (MAR sheets and CSMDR sheet missing)
· Personal Records (Administrator missing TB test)
Continued LIC 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CLEGG CARE FACILITY
FACILITY NUMBER: 340317817
VISIT DATE: 11/14/2023
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· Bed Bugs
· Reporting Requirements
· Residents Records
· Annual Training

The facility has stated they will agree to do the following:


· Licensee have put another refrigerator in the dining area made accessible to residents.
· Licensee have put another pantry out in the dining area made accessible to residents.
· Licensee agrees to follow plan of operation regarding falls. If a resident falls and can’t get up independently and will call 911 for assistant and not lift residents.
· Licensee agrees to notify the department regarding issuing eviction and following eviction procedures.
· Licensee have put in place a daily log of hot water temperature check.
· Licensee agrees to do a monthly maintenance and ground checklist.
· Licensee agrees to report UIR to the facility within 7 days and when administrator is out of town or have a designated person in place.
· Licensee agrees to ensure all staff received 20 hours of continue educations each year.
· Licensee agrees to use the CSMDR or MAR sheets to document residents’ medications being administered.Document Link Icon
· Licensee agrees to ensure staff and residents files are update and completed.

During today’s meeting it was discussed that TSP engagement is available and the Regional Office will make a referral to the Unit to provide services to the facility. Licensee declined TSP referral and will reach out to LPA if they decide take the TSP referral. The Regional Office (RO) will continue to monitor the facilities’ progress. The RO will continue increased monitoring to verify compliance with issues discussed during the meeting on 11/14/2023. The RO will revisit compliance in 9-12 months and begin the legal process if the facility is not in compliance.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023
LIC809 (FAS) - (06/04)
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