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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317817
Report Date: 02/16/2024
Date Signed: 02/16/2024 04:37:25 PM


Document Has Been Signed on 02/16/2024 04:37 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: 6DATE:
02/16/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Edna CleggTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a health and safety case management visit. The facility is on quarterly visits due to non-compliance concerns discussed during a zoom meeting on 11/14/2023. LPA Lee met with licensee, Edna Clegg and explained the purpose of the visit. The census is 6 with 2 facility staff.

During today's visit, LPA Lee reviewed facility records, residents medications and toured the facility. During the review of residents medications, LPA Lee observed medications made inaccessible to residents. LPA Lee also observed sharp objects made accessible to residents during today's visit. Due to insufficient time LPA Lee will return at a later date to complete the case management.

As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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 02/16/2024 04:37 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: CLEGG CARE FACILITY
FACILITY NUMBER: 340317817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
87465(h)(2)

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87465(h)(2) Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not meet as evidenced by:
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The licensee agrees to ensure before that all resident medications are locked at all times and made inaccessible to residents in care. The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. POC will be emailed to LPA Lee by POC date 02/23/2024 by POC date end of day 5:00 PM.
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Based on observations and interview the licensee did not comply with the section cited above. The licensee did not ensure that resident’s medication was made inaccessible to residents in care; which this poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.
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Type A
02/23/2024
Section Cited
CCR87309(a)

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9. 87309(a) Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement was not met as evidence by:


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Licensee removed multiple disinfectants and cleaning solutions and placed them in a locked cabinet. The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. POC will be emailed to LPA Lee by POC date 02/23/2024 by POC date end of day 5:00 PM.


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Based on observation and interviews, licensee did not ensure that multiple disinfectants and cleaning solutions were made inaccessible to residents in care, which poses a potential health and safety risk to persons in care. 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-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2