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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317817
Report Date: 12/12/2024
Date Signed: 12/12/2024 12:34:38 PM

Document Has Been Signed on 12/12/2024 12:34 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/
DIRECTOR:		CLEGG, EDNA SFACILITY TYPE:
740
ADDRESS:7249 CARMI STREETTELEPHONE:
(916) 429-6444
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 10CENSUS: 6DATE:
12/12/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Edna CleggTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Pang Lee arrived at facility unannounced to conduct a quarterly visit on 12/12/2024, LPA Lee met with administrator Edna Clegg and explained the purpose of the visit.

The purpose of the visit today is to conduct a quarterly visit. LPA toured 6 resident bedrooms. All rooms were observed to meet the resident's needs at this time. Living area, dining area and other resident areas were observed. Furniture was observed to be in good repair. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable food supply at this time. Toxins were observed to be locked and made inaccessible to residents. Smoke detectors and carbon monoxide was observed to be in good repair. Indoor temperature of the facility was 70 * F.

LPA Lee followed up with the following:

· Eviction Procedures: No current evictions issue.


· Personal Rights: kitchen and pantry were not lock during today’s visit.
· Fire Clearance: carbon monoxide detector and fire alarm was in good repair.
· Maintenance and Operation: facility hot water was measured at 112.5 * F.
· Incidental Medical and Dental Care Services: LPA Lee reviewed 2 out of 6 client MAR logs and they were not accurate. LPA observed two resident’s medication are in the bubble pack; however, the medications are not documented on the MAR logs.
· Personal Records: 2 facility staff files were reviewed, and it was complete and has TB test.
· Bed Bugs: facility does not have any bed bugs.

Continued LIC 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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 3
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: 12/12/2024
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· Reporting Requirements: LPA Lee reviewed Community Care Licensing Department (CCLD) Unusual Incident Report (UIR) LIC 624 files for December 2023 to December 2024 and did not observe any incident reports reported to the department. LPA Lee observed 5 resident’s file and there are no incident reports. Per administrator Edna and staff Maxwell residents don’t have any incidents and residents have not been to the hospital. LPA Lee observed resident 1 (R1)’s file and it was learned that R1 had hip surgery on 12/02/2024 and is still at the hospital during today's visit. It was also learned that on 04/19/23, R1 was in a serious car accident with R1’s service coordinator from Telecare. LPA Lee did not observe an incident report regarding the 04/19/23 incident in the file. An hour and a half later, staff Maxwell brought the LIC 625 incident report to LPA Lee. It was also learned that the facility does not keep fax receipt. The facility was not able to provide LPA Lee proof of incident reports being reported/fax to the department.
· Resident Records: LPA Lee reviewed 6 resident’s file and they were complete; however, LPA Lee observed 6 out of 6 resident’s LIC 625 Needs and Service Plans are missing the resident/conservator signature.
· Facility staff annual training: LPA Lee reviewed 2 staff files and it was complete and the staff had the required continued annual training.

As a result of this quarterly 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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2024 12:34 PM - It Cannot Be Edited


Created By: Pang Lee On 12/12/2024 at 11:57 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CLEGG CARE FACILITY
FACILITY NUMBER: 340317817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2024
Section Cited
CCR
97465(c)(3)

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87465 Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication…
(3) A record of each dose is maintained in the resident's record...

This requirement was not met as evidence by:
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The administrator agrees to read the regulation being cited today and submit a signed declaration of understanding. The administrator will also conduct an in-service for Incidental Medical and Dental Care training in regard to the regulation being cited and provided LPA Lee documents used for the training.
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Based on records review and interviews the Licensee did ensure that resident’s medication record is maintained. This posed a immediate health and safety risk to residents in care.
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The administrator will also provide LPA Lee a staff sign in sheet. POC will be emailed to LPA Lee at pang.lee@dss.ca.gov by 12/19/2024 by end of day 5:00 PM
Type B
12/19/2024
Section Cited
CCR97211(a)(1)

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87211(a)(1) Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified…

This requirement was not met as evidence by:
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The administrator agrees to read the regulation (Reporting Requirement) being cited today and submit a signed declaration of understanding. The administrator will also train all facility staff in regard to the regulation being cited today and provided LPA Lee documents used for the training.
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Based on records review and interviews the licensee is not ensuring that incident reports are being reported to CCLD. This posed a potential health and safety risk to residents in care.
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The administrator will also provide LPA Lee a staff sign in sheet. POC will be emailed to LPA Lee at pang.lee@dss.ca.gov by 12/19/2024 by 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-Lee
LICENSING EVALUATOR NAME:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
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