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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700151
Report Date: 08/24/2023
Date Signed: 08/24/2023 12:51:34 PM


Document Has Been Signed on 08/24/2023 12:51 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:ORANGE GROVE SENIOR LIVINGFACILITY NUMBER:
342700151
ADMINISTRATOR:TORRES,CHRISTINEFACILITY TYPE:
740
ADDRESS:228 GRACE AVENUETELEPHONE:
(916) 993-9099
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY:6CENSUS: 6DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Christine TorresTIME COMPLETED:
01:00 PM
NARRATIVE
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On 08/24/2023 at 8:00 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care staff, Teresa Autencio and her husband Geronimo, who then called administrator, Christine Torres. Administrator, Christine arrived approximately one hour later. LPA Lee explained the purpose of the visit. Administrator, Christine assisted with today’s visit. Administrator certificate # is 6042576740 and will expire on 10/23/2024. The current census is 6 with 2 facility staff.

This facility is a two story building licensed to serve three (3) non-ambulatory residents and three (3) ambulatory residents. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor and clean. LPA Lee observed resident room #4 intercom box not in good repair with exposed wired. 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. Hot water temperature was measured at 127.8 degrees Fahrenheit in resident bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit. Fire alarm and carbon monoxide detectors are in compliance with fire safety. LPA Lee observed one fire extinguisher in the kitchen without a service tag or a receipt of purchased on the fire extinguisher. LPA Lee also observed two fire extinguisher in the upstairs hallway. The second fire extinguisher also did not have a service tag and receipt attached to it. The third fire extinguisher service tag was dated on 09/04/2018. LPA Lee observed the facility has a has a public telephone in the common room and the facility have the required posters posted. The facility has infection control plan and has an emergency disaster plan. Facility thermostat observed at 74 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to clients.
Continued LIC 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ORANGE GROVE SENIOR LIVING
FACILITY NUMBER: 342700151
VISIT DATE: 08/24/2023
NARRATIVE
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LPA Lee reviewed 3 out of 3 medication administration record (MAR) and it was complete. LPA Lee observed one resident medication is not in it's original box. First aid kit was checked and is complete. LPA Lee requested residents and staff files for review. LPA Lee reviewed 6 out of 6 resident files and 6 out of 6 resident file was not complete. LPA Lee reviewed 3 out of 6 staff files and 3 out of 6 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.

The following documents were given to LPA Lee during today's visit.

(1) LIC 308 Designation of Administrative Responsibility


(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

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, LIC 9102 Technical Violation and Appeals rights were provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 08/24/2023 12:51 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: ORANGE GROVE SENIOR LIVING
FACILITY NUMBER: 342700151

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
87411 Personnel Requirements - General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee did not ensure 3 out of 6 facility staff files were current and up to dare, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2023
Plan of Correction
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LIicensee agrees to up date facility staff files and notify LPA Lee by POC date 09/08/2023 by 5:00 PM by end of day. LPA Lee gave administrator a copy of what is missing in 3 staff file form LIC 859 on a word document.
Type B
Section Cited
CCR
87506(a)
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LIcensee did not ensure 6 out of 6 residents file were current and complete,] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2023
Plan of Correction
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Licensee agrees to up complete and up date 6 out 6 resident files and notify LPA Lee by POC date 09/08/2023 by 5:00 PM by end of day. LPA lee gave administrator a copy of what is missing in the 6 residnet's file from LIC 858 on a word document.
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: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 08/24/2023 12:51 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: ORANGE GROVE SENIOR LIVING
FACILITY NUMBER: 342700151

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. Licensee did not ensure resident room #4 was in good repair. There's a broken intercome lose coming out of the wall with exposed wire, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee agrees to remove the broken intercome and patched the hole in the wall by POC date 08/25/2023 by 5:00 PM by end of day. Licensee agrees to email LPA Lee at pang.lee@dss.ca.gov a picture of the intercome removed with the hole in the wall patch with no exposed wire.
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: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 8 of 8