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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700136
Report Date: 06/16/2022
Date Signed: 06/16/2022 03:55:27 PM

Document Has Been Signed on 06/16/2022 03:55 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:HARVEY ESTATEFACILITY NUMBER:
342700136
ADMINISTRATOR:KHAN, HANIFFACILITY TYPE:
735
ADDRESS:9812 HARVEY ROADTELEPHONE:
(209) 329-5689
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 4CENSUS: 4DATE:
06/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Brittney ChavesTIME COMPLETED:
04:01 PM
NARRATIVE
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On 6-16-22 at 2:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a reported incident on 6-7-22. LPA met with house manager Brittney Chaves and explained the purpose of the visit. Administrator Hanif Khan was not present and was notified by phone of LPA's visit and purpose. LPA reviewed incident report with house manager. LPA also interviewed house manager and conducted facility tour. LPA also reviewed medication training material. Based on interviews and review of incident occurring on 6-6-2022, Resident1 (R1) was given another client's medication by mistake during bedtime medication preparation. Reporting requirements were followed and Physician was notified. Facility has initiated re-training of facility's medication training program as of 6-14-22. LPA reviewed care notes for R1 which state R1 did not experience negative side effects as a result of the medication error.

Based on interviews and record reviews, citation is issued under Title 22, Division 6. An exit interview was conducted with Brittney Chaves and a copy of this report was left with Brittney. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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 06/16/2022 03:55 PM - It Cannot Be Edited


Created By: Michael Bilger On 06/16/2022 at 02:27 PM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: HARVEY ESTATE
FACILITY NUMBER: 342700136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2022
Section Cited
CCR
80075(b)

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Health Related Services. (b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
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Licensee will ensure staff re-training of facilities medication policies and procedures. Proof of scheduled training to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA no later than 6-23-22.
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Based on interview and record review, Licensee did not ensure R1 was appropriately assisted with self-administration of medications, in that R1 received medication prescribed for another client. This poses an immediately 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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


LIC809 (FAS) - (06/04)
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