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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700222
Report Date: 12/03/2024
Date Signed: 12/03/2024 01:08:08 PM

Document Has Been Signed on 12/03/2024 01:08 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:ASTORGA HOME LLCFACILITY NUMBER:
342700222
ADMINISTRATOR/
DIRECTOR:		ASTORGA, ANTONIETTEFACILITY TYPE:
734
ADDRESS:8210 DAISY HILLTELEPHONE:
(916) 236-3390
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 5CENSUS: 4DATE:
12/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:James AstorgaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit. LPA Valerio met with facility staff, and explained the purpose of the visit. LPA Valerio was later met by licensee James Astorga.
On 11/06/2024, Department of Developmental Services (DDS) conducted an onsite Semi-Annual Review and found multiple areas of concern that are being addressed with the provider and Alta California Regional Center. LPA Valerio followed up on the following concerns:
  • Per the DDS review, when staff take Resident 1 (R1) on a walk outside around in the backyard of the facility, they do not take R1's spare tracheostomy tube. Per the facility policy and procedure for tracheostomies, there should be a spare tracheostomy tube with the individual “at all times.”
      • - LPA Valerio reviewed R1's Individual Health Care Plan, Physicians Orders dated 08/06/24, 09/30/24, and 11/15/24, and Individual Program Plan. LPA Valerio reviewed the facility's Nursing Polices and Procedures and inspected R1's bedroom. Based on LPAs review and observation, LPA Valerio did not observe an order or procedure indicating a spare tracheostomy tube to be with the individual at all times. LPA Valerio interviewed nursing staff, respiratory staff, and the licensee. According to interviews, a licensed professional is with R1 at all times, including when R1 goes into the yard for an outing. The distance from the yard to R1's room is > one minute walk. If R1 goes into the community, a portable medical devices and spare tubes are with the licensed professional at all times.
  • The home had a GI virus outbreak in which three of the four clients experienced nausea and vomiting within a two-day period. This was not reported to DDS. LPA conducted a file review prior to the visit and found 0 incident reports indicating a GI virus outbreak.
      • - LPA Valerio reviewed nursing notes for R1, R2, and R3. LPA Valerio observed residents to have separate occurrences of vomiting or nausea. LPA Valerio did not observe where the residents received a diagnosis of a viral infection. Therefore, there is no need for the facility to report an outbreak.
      - Technical Assistance was provided for Title 22 Reporting Requirements for any future reportable incidents.
    Per California Code of Regulations (CCR) - Title 22 - Technical Assistance was provided and no deficiencies are being cited. An exit interview was held with Licensee James, and a copy of the report was provided.
    SUPERVISORS NAME: Stephen Richardson
    LICENSING EVALUATOR NAME: Christina Valerio
    LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
    I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
    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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