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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700029
Report Date: 09/26/2024
Date Signed: 09/26/2024 01:23:03 PM


Document Has Been Signed on 09/26/2024 01:23 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:CALI CARE RETIREMENT HOMEFACILITY NUMBER:
342700029
ADMINISTRATOR:MOJICA, CYNTHIAFACILITY TYPE:
740
ADDRESS:3630 WEST WAYTELEPHONE:
(916) 484-3027
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 5DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Cynthia MojicaTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Holly Williams and LPM Czarrina Camilon-Lee arrived unannounced to conduct an annual inspection. LPA Holly Williams and LPM Czarrina Camilon-Lee met with facility administrator Cynthia Mojica and explained the purpose of the visit.

Licensing Program Analyst Holly Williams interviewed 4 staff files (S1-S4) and 5 resident files (R1-R5).LPA Williams and LPM Czarrina Camilon-Lee observed during record review that 3 out of the 4 file staff files did not have a personnel record. According to record review and observation resident R4 has a catheter and there is no care plan available to be reviewed in resident file.

LPA Williams and LPM Camilon-Lee toured the facility with Mojica and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 71 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 120 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. The fence on the south west side of the backyard is falling over and Mojica was given a technical advisory for that.

LPA Williams and LPM Camilon Lee observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Williams and LPM Camilon-Lee observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Williams and LPM Camilon-Lee observed a locked cabinet for the storage of medication. LPA Williams and LPM Camilon-Lee observed locked cabinets for the storage of cleaning solutions and knives. During the visit LPA Williams and LPM Camilon Lee observed medication was out on the counter and in a one day a week pill box for all residents.

Continued 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
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: CALI CARE RETIREMENT HOME
FACILITY NUMBER: 342700029
VISIT DATE: 09/26/2024
NARRATIVE
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LPA Williams and LPM Czarrina Camilon-Lee interviewed one staff (R2) and one resident (R2).
This facility is being cited per 22 CCR section 87465(h)(2), 87609(a)(b)(4)(A), 87412(a). An exit interview was held with Mojica. Appeal rights and a copy of this report were given to Mojica.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/26/2024 01:23 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: CALI CARE RETIREMENT HOME
FACILITY NUMBER: 342700029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel 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
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Based on record review, the licensee did not have personnel records for 3 out of the 4 files reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2024
Plan of Correction
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Licensee agrees to have the personnel records complete by the POC date. Holly.Williams@dss.ca.gov
Type B
Section Cited
CCR
87609(a)(b)(4)(A)
(a) A licensee shall be permitted to accept or retain persons who have a health condition(s) which requires incidental medical services including, but not limited to, the conditions specified in Section 87612, Restricted Health Conditions.
(b)Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met:
(4)The licensee and hiome health agency agree in wreiting on the responsibilities of the home health agency, and those of the licensee in caring for the residents conditions.
(A)The written agreement shall reflect the services , frequency, and duration of care.

This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not include a care plan for the cather that the resident has which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2024
Plan of Correction
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Licensee agrees to develop a care plan for the resident that has the catheter and email it to Holly.williams@dss.ca.gov by POC date.
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) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/26/2024 01:23 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: CALI CARE RETIREMENT HOME
FACILITY NUMBER: 342700029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(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 met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not keep medications locked up which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee agrees lock up medication and provide training to staff. Licensee agrees to send statment by POC due date of the regulation and plan for training to be done. and send sign in sheet. Holly.williams@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4