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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700067
Report Date: 04/29/2022
Date Signed: 04/29/2022 11:34:39 AM


Document Has Been Signed on 04/29/2022 11:34 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:HOSPITALITY HOUSEFACILITY NUMBER:
342700067
ADMINISTRATOR:LORRAINE PADILLAFACILITY TYPE:
740
ADDRESS:5400 KIERNAN AVENUETELEPHONE:
(209) 543-9275
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:80CENSUS: 37DATE:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Valerie Arreola - Medication TechnicianTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required – 1 Year Inspection Visit. LPA met with Medication Technician and stated the purpose of today’s visit. LPA was allowed entry into the facility which currently has 37 residents. Facility has an approved hospice waiver for 15. Administrator Certificate expires 09/18/2022.

LPA observed residents during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed the facility conducts fire and disaster drills quarterly and annually. Smoke and carbon monoxide detectors, central heating and air and pull alarm system in the facility. Hot water temperature was measured in a resident bathroom and it measured at 106.7 F degrees which is in the required range of 105 to 120 degrees.
LPA observed fire extinguisher tags expired 10/07/2021. LPA verified the last Fire Drill was conducted on 01/25/2022. LPA observed toxins locked up and stored in closet . LPA observed 2 day perishable and 7 day non-perishables during this visit.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA reviewed (6) staff files. All staff is fingerprint cleared and associated to the facility and staff currently have First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. LPA reviewed 8 resident files which have all Community Care Licensing (CCL) documents as required. LPA reviewed 3 of resident medication files, which were completed .


See deficiency cited from California Code of Regulations, Title 22, Division 6 of California Regulation. See LIC 809-D. Immediate Civil Penalty of $500.00 assessed. Failure to correct the deficiency may result in additional civil penalties.
An exit interview was conducted with medication technician. LPA left copies of reports and appeal rights with medication technician.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
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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Document Has Been Signed on 04/29/2022 02:15 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/29/2022 02:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: HOSPITALITY HOUSE
FACILITY NUMBER: 342700067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in fire extinguisher tags expired 10/07/2021 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2022
Plan of Correction
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Licensee agrees to purchase fire extinguisher during annual inspection to clear Plan of Correction (POC) on 4/29/2022.
Immediate civil penalty of $500.00 was assessed. No further action required.
ruth.wallace@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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
LIC809 (FAS) - (06/04)
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