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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700184
Report Date: 02/20/2024
Date Signed: 02/20/2024 11:16:25 AM


Document Has Been Signed on 02/20/2024 11:16 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SHEARWATER RESIDENCEFACILITY NUMBER:
342700184
ADMINISTRATOR:THOMAS, REBECCAFACILITY TYPE:
740
ADDRESS:6526 MAIN AVETELEPHONE:
(916) 989-1060
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:16CENSUS: 14DATE:
02/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator- Rebecca ThomasTIME COMPLETED:
11:25 AM
NARRATIVE
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On 02/20/24 Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify administrator of LPA's presence at the facility. Staff called administrator Rebecca Thomas and administrator spoke with LPA via phone. Administrator, Rebecca Thomas arrived at the facility shortly after and assisted LPA with today's visit.

LPA and administrator conducted a tour of the facility. Areas toured included but not limited to the kitchen, dining room, residents bedrooms, bathrooms, common areas and backyard. LPA observed sufficient furniture and lighting throughout the facility.

LPA observed the facility to have sufficient food supplies for seven (7) day non-perishable and two (2) day perishable. LPA observed toxins, knives and centrally stored medications to be locked and inaccessible to residents in care. All required Licensing posters are present in common area in the facility. The temperature in the facility was 74 degrees. Fire extinguishers was last inspected on 07/25/23. Smoke and carbon monoxide detectors are working and present throughout the facility. First Aid kit is maintained and ready for emergency use.

LPA conducted a file review of four (4) resident files . LPA compared medications to those being given for four (4) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). Additionally, LPA reviewed three (3) personnel records which had all required documents.

LPA requested a copy of the current liability insurance and LIC500 to be sent to LPA Bains by 03/10/24.

LPA completed the full care tool and deficiencies were observed per CCR ,Title 22 Regulations as indicated on 809-D. Exit interview conducted .Appeal Rights and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
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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Document Has Been Signed on 02/20/2024 11:16 AM - 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: SHEARWATER RESIDENCE
FACILITY NUMBER: 342700184

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)(3)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff's interviews and record review, the licensee did not comply with the section cited above as reappraisal was not completed to addrress resident, R2 ,Change in helath condition for stage 3 pressure injury as indicated in LIC602 ,dated-09/25/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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Facility will complete reappraisal to addrress resident, R2 ,Change in helath condition for stage 3 pressure injury as indicated in LIC602 ,dated-09/25/23 and will notify department by POC Date-03/19/24 with proof of documents.
Type B
Section Cited
CCR
87615(a)(1)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure sores (dermal ulcers).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff's interviews and record review, it has been found that facility retain resident, R2 with pressure injury, stage 3 which is a Prohibited Health Condition for RCFE and did not have Approved Exception to provide care and services which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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Licensee/administrator shall send letter of understanding of this regulation and shall apply for Exception Request to retain resident with stage 3 wound/pressure injury as required . All POC documents are due by 03/19/24.
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 MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
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