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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700154
Report Date: 09/29/2022
Date Signed: 09/29/2022 12:43:42 PM

Document Has Been Signed on 09/29/2022 12:43 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:LUCERO MANORFACILITY NUMBER:
342700154
ADMINISTRATOR:LUCERO, LOVELLA N RN BSNFACILITY TYPE:
734
ADDRESS:9551 SOUTH CANYON COURTTELEPHONE:
(650) 580-3896
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 5CENSUS: 5DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator- Bessie MadrioTIME COMPLETED:
01:00 PM
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On 09/29/22, Licensing Program Analysts (LPAs) Sabrina Calzada ,Talwinder Bains and DDS Nurse- Laura Mefford arrived unannounced to conduct a required annual. LPAs and DDS Nurse met with Administrator, Bessie Madrio and explained purpose of inspection.

Prior to initiating today's inspection, LPAs completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. Additionally, LPAs and Nurse were screened per Covid-19 precautionary measures upon entering the facility. LPAs ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95/Surgical masks. The facility is a licensed home for residents with special health care needs and is vendorized through Alta California Regional Center. There are (5) clients who reside at the home. These staff were working at facility during today's visit- DSP John Paul Bautista, DSP Manuel Asuncion, 1 agency staff and 1 RT.

LPAs , Administrator and DDS nurse toured the interior of the facility including the common areas, client (5) bedrooms, bathrooms, kitchen, laundry area and garage and observed the home to be clean, safe and in good repair . LPAs observed various Covid posters throughout. Inside temperature was observed to be 70* F. Fire extinguisher last serviced 02/15/22. LPAs observed sufficient 2+day perishable and 7+day non-perishable food for (1) client that are able to eat solid/pureed food and G-tube liquid for (4) clients. LPAs observed paper towels, soap, sanitizer, trash cans with lids. Facility to ensure 20-second hand-washing posters are posted by each sink in the bathrooms and kitchen. LPA observed sufficient PPE supply on hand with cart at front entrance and by resident rooms. LPA's observed additional PPE and other supplies in the garage.

*report continue to 809-C....
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: LUCERO MANOR
FACILITY NUMBER: 342700154
VISIT DATE: 09/29/2022
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continue from 809----

During inspection, around 10.30am, LPAs and DDS nurse observed medication closet to be unlocked and treatments for (2) clients to be not secured and accessible to residents in care. (1) client is able to ambulate in her wheelchair. See 809D page for citation to be issued today per Title 22, Division 6, Chapter 8.


A Technical Advisory Note was issued also due to LPA's and DDS nurse observing (2) of (5) clients' head of the bed to not be at the correct degree/position.

Exit interview with Administrator. Copy of report and Appeal Rights provided to Administrator.




SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2022 12:43 PM - It Cannot Be Edited


Created By: Talwinder Bains On 09/29/2022 at 12:04 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: LUCERO MANOR
FACILITY NUMBER: 342700154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication 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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LPAs and DDS observed that medication cabinet was left unlocked, medications were left opened for 2 of 5 residents and accessible to residents in care which poses a immediate health and safety risks to residents in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee will send statement of understanding of regulation 80075(k)(1) by POC date- 09/30/22 to CCL. Licensee will do training with staff for correct documentation on the MAR and proper medication protocols per regulation 80075(k)(1) by POC date- 10/15/22.
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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
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