340317817-5-3-2023-27-AS-PLEE-CRGV62-20230503160849

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 340317817
Report Date: 05/03/2023
Date Signed: 05/03/2023 04:09:10 PM

Document Has Been Signed on 05/03/2023 04:09 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	CLEGG CARE FACILITY		FACILITY NUMBER:	340317817
ADMINISTRATOR:	CLEGG, EDNA S		FACILITY TYPE:	740
ADDRESS:	7249 CARMI STREET		TELEPHONE:	(916) 429-6444
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	10	CENSUS:	DATE:	05/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Edna Clegg		TIME COMPLETED:	04:30 PM

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Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection on 05/03/2023 at 8:40 AM, LPA Lee met with Licensee/Administrator Edna Clegg and explained the purpose of the visit. Administrator certificated number # 6017600740 expires on 07/15/2024. Administrator assisted with today’s visit.

LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. The facility has one public telephone one in the kitchen area. The facility has the required posters posted in the facility. This facility is a single story building licensed to serve ten (10) residents. LPA observed one of the cabinet in the kitchen is broken. LPA observed one resident’s room having urine odor. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Lee observed sufficient seven-day non-perishable and two-day perishable food supplies. The resident bathroom water temperature measured at 107.6 degrees Fahrenheit which is within the required regulation of 105 to 120 degrees Fahrenheit. LPA observed two bathrooms with no nonskid mats and having urine odor with urine stain on the wall and around the toilet. Fire extinguishers and smoke detectors are in good repair. Fire extinguisher was last serviced on 07/14/2022. LPA observed the carbon monoxide off the wall and on top of a shelf and not working. Facility thermostat observed at 63 degrees Fahrenheit. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA reviewed 4 out of 8 Centrally Stored Medication and Destruction Report and it was not complete. First aid kit was checked and is complete. LPA Lee requested client and staff files for review. LPA reviewed 4 out of 8 client files and 1 out of 4 resident file was not complete. LPA reviewed 3 out of 6 staff files and 3 out 3 staff files were not complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CLEGG CARE FACILITY	FACILITY NUMBER: 340317817
	VISIT DATE: 05/03/2023

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The following documents will be emailed to LPA Lee by Licensee by 05/08/2023 by 5:00 PM of business day.
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Proof of Current Liability Insurance
(4) LIC 610 Emergency Disaster Plan
(5) Current Administrator Certificate

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, Technical Advisory (TA) and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/03/2023 04:09 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CLEGG CARE FACILITY	FACILITY NUMBER: 340317817
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not ensure there was a working carbon monoxide dectors which poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 05/03/2023
	Plan of Correction
1 2 3 4	Licesee had a staff purchased a brand new carbon monoxide detector and mounted the carbon monoxide detector back on the wall. Licensee tested the carbon monoxide detector and it is now working properly.

Type A

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not ensure bathrroms had non-skid mats which poses an immediate health, safety or personal rights risk to resident in care.
	POC Due Date: 05/03/2023
	Plan of Correction
1 2 3 4	Licensee had another staff purchased two non-skid mats. Licensee placed the non-skid mats in both showers.

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	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/03/2023 04:09 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CLEGG CARE FACILITY	FACILITY NUMBER: 340317817
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not ensure 1 out of 3 resident had a MAR log sheet or CSMDR sheet which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Licensee will complete MAR log or CSMDR sheet for R2 and send LPA Lee a copy. Licensee will also complete and reviewed regulations/training for resident file requirement and send statement of review of regulations or trainings.

Type B

Section Cited

CCR

87412(a)

(a) The Licensee shall ensure that personal records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not ensure administrator had a TB completed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Licensee stated that she believeds she got her TB complete, but doesn't know where the documet is. Licensee called and made an appointment for TB test at McClellan Clinic at 6:30 PM today, 05/03/2023. LIcensee will email LPA a copy of TB test and result by 05/08/2023 by 5:00 PM bussiness hours.

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	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/03/2023 04:09 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CLEGG CARE FACILITY	FACILITY NUMBER: 340317817
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(6)

87411(c)(6) Personal Requirement (c) All RCFE staff who assist residents with peronal activities of daily living shall receive initial and annual training.... (6) The licensee shall maintain documentation pertaining to staff training in the personnel records..... requiremtn is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not ensure that 2 out of 3 staff had their annual trainings from last year and any current trainings completed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/19/2023
	Plan of Correction
1 2 3 4	Licensee will make sure S1 and S2 register for caregiver trainings and have their annual trainings completed. Lincensee will ensure that staff trainings stays current. Lincess will review care staff training regulations and send LPA documents of completed trainings and a statement of the review regulatons. LIicensee will send LPA copies by POC date 05/19/2023 by 5:00 PM

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

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