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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317817
Report Date: 02/16/2024
Date Signed: 02/21/2024 11:51:21 AM


Document Has Been Signed on 02/21/2024 11:51 AM - 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:TIME COMPLETED:
04:45 PM
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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.

At 8:31 AM, LPA Lee entered the facility and observed three residents sitting in the common area watching a movie. The residents appeared to be clean and comfortable. LPA Lee and licensee Edna Clegg toured the physical plant to ensure compliance with Title 22 regulations. LPA Lee observed resident bedrooms, bathrooms, common areas, dining area, laundry room, kitchen, and exterior plants of the facility. LPA Lee observed resident bedrooms to have the necessary furniture and furnishings. The temperature inside the home was measured at 72*F. LPA Lee observed the fire extinguisher located in the kitchen next to the pantry. The fire extinguisher was last serviced on 12/01/2023. LPA Lee observed the carbon monoxide and fire alarm was in good repair. LPA Lee observed no emergency exits were obstructed. The first aid kit was checked and contained all the required components.

At 8:43 AM, LPA Lee also observed multiple chemicals made accessible to residents in care. At 8:45 AM, LPA Lee observed a mini refrigerator out in the dining area unlocked. LPA Lee observed 4 water bottles, 1 Sunsweet prune juice and a 26 Fl oz Phillips milk of magnesia inside the mini refrigerator. It was learned that magnesia is for resident 1 (R1) and there is no PRN order and doctor’s note for (R1). Based on interview, licensee Edna Clegg admitted to buying (R1) the Sunsweet prune juice for (R1) constipation without a doctor’s order or note. LPA Lee advised licensee that any resident PRN medication needs a doctor’s order or a doctor’s note. LPA Lee also advised licensee that she can not give (R1) prune juice without a doctor’s order or note.

Continued LIC 809-C
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 7


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: 02/16/2024
NARRATIVE
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 At 8:48 AM, LPA Lee observed a knife on top of the kitchen counter and two scissors on the dish rack made accessible to residents in care. LPA Lee asked the licensee where she kept sharp objects and the license stated that she keeps them in a drawer below the dish rack. LPA Lee observed the drawer unlocked and inside the drawer LPA Lee observed four knives. Licensee continues to show LPA Lee where the additional knives are kept as well. Additional knives were kept on a kitchen shelf made accessible to residents. At 8:52 AM, LPA Lee observed (R2) Latanoprost medication and licensee eye drops in the refrigerator made accessible to residents and stored with condiments. Licensee admitted that (R2) is no longer taking (R2) Latanoprost medication. Based on observation (R2) Latanoprost medication was supposed to be discarded after 09/30/2021. During today’s visit, LPA Lee observed licensee removed (R2) and licensee’s eye drop from the refrigerator. LPA Lee advised the licensee that all sharp objects and chemicals need to be locked at all times. LPA Lee also advised licensee that all resident’s medication needs to be made inaccessible to resident at all times. LPA Lee also advised licensee that medications cannot be stored with food.

Based on observations today, at 8:55 AM, LPA Lee observed resident bathroom #1 toilet seat was not in good repair. The top of the seat is broken. The toilet was also observed to be unclean. During the inspection Licensee cleaned the toilet and apologized for it being unclean. LPA Lee also observed licensee fixed broken toilet. The resident bathroom observed to have handrails and non-slip mat.



At 8:57 AM, LPA Lee observed resident bedroom #4 sliding door is hard to open and the sliding screen is not in good repair due to rips and holes. Based on records review at 9:10 AM, LPA Lee observed waterlog only from 09/01/2023 to 09/11/2023. At 9:30 AM, LPA Lee measured the water temperature and it a measured at 115.2 degrees Fahrenheit which is within the required regulations of 105 to 120 degrees Fahrenheit. Based on records review and interviews with licensee Edna and caregiver Maxwell Llorente admitted to not having a maintenance and ground checklist completed. Maxwell stated that he will create a maintenance and ground checklist and provide it to LPA Lee. At. 10:29 AM, LPA Lee observed a small tray of snacks out in the dinning island counter. Inside the tray were 8 small packs of 0.2 oz of Frootloops cereal and 1 pack of 6 oz Whisp Cheese Crips bag.

At 10:37 AM, LPA Lee observed 10 of (R1) medication Clobetasol Propionate lotion in an unlocked cabinet in the laundry made accessible to residents. During today’s visit, LPA Lee observed licensee removed (R2) and licensee’s eye drop from the refrigerator.


Continued LIC 809-C

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
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: 02/16/2024
NARRATIVE
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LPA requested to review resident files and staff files. LPA Lee reviewed 6 out of 6 resident files and 4 out of 6 staff files, and they were not complete. LPA Lee observed 6 out of 6 resident’s LIC 625 Appraisal Needs and Services was completed; however, it does not have licensee and residents’ signature. LPA Lee also observed 6 out of 6 residents missing LIC 601 in the file. LPA Lee observed 4 out of 6 facility staff files missing 20 hours of continued education for the year 2023.

LPA Lee reviewed and compared 6 out of 6 residents medication records. Licensee stated that she does not use the MAR to administer residents’ medication. It was learned that licensee uses the Centrally Store Medication Destruction Record (CSMDR); however, based on records review and observations the licensee did not keep adequate records of the (CSMDR) for 6 out of 6 residents. LPA Lee observed (R3) (CSMDR) last start dated was 03/11/2022. LPA Lee observed (R2) (CSMDR) last start dated was on 02/07/2019. In addition, (R2) (CSMDR) shows (R2) has medication Benztropine 0.05 mg; however, the medication was not in resident medication box. Licensee admitted that (R2) is no longer take Benztropine. LPA Lee also observed 5 out of 6 residents (CSMDR) does not have a start date of when all of resident’s medication was administer to residents.

As a result of this annual 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
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/21/2024 11:51 AM - 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 B
02/28/2024
Section Cited
ILS
87465(e)

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87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician…
This requirement is not meet as evidenced by:

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The licensee agrees to ensure before that all resident has a doctor’s order or note prior to any PRN medication being administered to residents in care. The licensee will review the regulation cited
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Based on observations, interviews, and record review, the licensee did not comply with the section cited above. The licensee did not ensure that R1 had a doctor’s order for magnesia and Sunsweet prune juice, which poses a potential health and safety risk to persons in care, which this posed a potential health and safety risk to residents in care.

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and write a statement of acknowledgement of understanding of the regulation cited. POC will be emailed to LPA Lee by POC date 02/28/2024 by POC date end of day 5:00 PM.

Type B
02/28/2024
Section Cited
CCR87465(h)(6)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

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The licensee agrees to ensure that all resident centrally stored prescriptions medications records are adequate and up to date at all times. The licensee will review the regulation cited and write a statement of acknowledgement of
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Based on observations record review the licensee did not comply with the section cited above. The licensee did not ensure that residents’ that a record of centrally store prescription of medications for residents were maintained, 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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understanding of the regulation cited. The licensee will send LPA Lee updated (CSMDR) records for 6 out of 6 residents for the month of February 2024. POC will be emailed to LPA Lee by POC date 02/28/2024 by POC date end of day 5:00 PM.

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: 4 of 7


Document Has Been Signed on 02/21/2024 11:51 AM - 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 B
02/28/2024
Section Cited
CCR
87405(c)

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87405 Administrator - Qualifications and Duties
(c) Failure to comply with all licensing requirements pertaining to certified administrators may constitute cause for revocation of the license of the facility.
This requirement is not meet as evidenced by:
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The licensee agrees to review NCC report on 11/14/2023 and comply with what licensee stated and agrees to follow during NCC meeting on 11/14/2023. The licensee will review the regulation cited and write a statement of
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Based on observations, record review, and interview the licensee did not comply with the section cited above. The licensee did not ensure that licensee complies with all licensing requirements during NCC meeting on 11/14/2023; 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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acknowledgement of understanding of the regulation cited. POC will be emailed to LPA Lee by POC date 02/28/2024 by POC date end of day 5:00 PM.
Type B
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Section Cited
CCR87405(d)

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87405 Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
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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 02/28/2024 by POC date end of day 5:00 PM.
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Based on observations, record review, and interview the licensee did not comply with the section cited above. The licensee did not ensure that licensee complied with all title 22 regulations knowledge of and ability to conform to applicable laws, rules and regulations, 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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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: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 02/21/2024 11:51 AM - 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 B
02/28/2024
Section Cited
CCR
87411(c)

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87411 Personnel Requirements – General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
This requirement is not meet as evidenced by:

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The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. Licensee will ensure and conduct training for all facility staff
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Based on observations, record review, and interview the licensee did not comply with the section cited above. The licensee did not ensure that 4 out of 6 staff are receiving initial and annual training. Based on record review, no training for 2023 was documented for 4 out of 6 staff files, 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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and ensure training are documented. Licensee will send proof of initial training for staff for 2024. POC will be emailed to LPA Lee by POC date 02/28/2024 by POC date end of day 5:00 PM.
Type B
02/28/2024
Section Cited
CCR87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors…

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The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. The licensee agrees to have the sliding door screen repaired.
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Based on observations the licensee did not comply with the section cited above. The licensee did not ensure that the resident bathroom and the sliding door screen were in good repair, 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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During today’s visit LPA Lee observed the licensee fix the broken toilet seat. POC will be emailed to LPA Lee by POC date 02/28/2024 by POC date end of day 5:00 PM.
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: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 02/21/2024 11:51 AM - 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 B
02/28/2024
Section Cited
CCR
87555(b)(24)

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8. 87555 General Food Service Requirements
The following food service requirements shall apply...Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored. This requirement was not met as evidence by:
This requirement is not meet as evidenced by:
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Facility staff remove resident and licensee medication out of resident food. 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 02/28/2024 by POC date end of day 5:00 PM.


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Based on observation and interview Licensee did not ensure insulin medication was stored separately from resident food, 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: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7