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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700238
Report Date: 08/31/2021
Date Signed: 08/31/2021 03:41:15 PM

Document Has Been Signed on 08/31/2021 03:41 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:SEVEN STARS CARE HOMEFACILITY NUMBER:
342700238
ADMINISTRATOR:SARAH MIKAILFACILITY TYPE:
735
ADDRESS:1317 COFFEE VILLA DRIVETELEPHONE:
(209) 595-8534
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 4DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Sarah Mikail, AdministratorTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA met with Sarah Mikail, Administrator.
LPA conducted gateway questions prior to visiting facility. AD completed symptom check upon entry and sign in sheets available to document all visitors.
LPA and AD, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas.
LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured 106.3 degrees in residents bathroom with the AD which is in required range of 105 to 120 degrees.
Last Fire Drill conduced dated 8/5/21. Fire extinguisher maintained 6/25/2021.
Fire alarm and carbon monoxide functional. LPA and AD observed centrally stored medications. LPA observed sharps and toxins locked.
LPA reviewed 2 staff and 4 clients files. Client emergency contact complete. LPA observed all staff files complete. Administrator Certificate valid until 10/8/21..
All persons in facility fully vaccinated. LPA observed clients wearing masks. LPA observed 30 days PPE supply. First aid kit complete.
LPA observed the backyard with 3 emergency exit points. LPA observed old equipment, old mattress, and unused satelite dish and water heater in backyard.
Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2021
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 08/31/2021 03:41 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 08/31/2021 at 12:03 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: SEVEN STARS CARE HOME
FACILITY NUMBER: 342700238

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2021
Section Cited

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80068.2 Needs and Services Plan (a) The licensee shall complete a Needs and Services Plan for each client as required in Sections 81068.2, 82068.2, 82568.2, or 85068.2.

(b) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that:
(1) The needs appraisal or IPP is not more than one year old.
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This regulation was not met by evidence of based on records reviewed, LPA observed 2 of the 4 residents IPPs last dated in 2018 and 2019. This poses a potential risk to the clients.
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Type B
09/10/2021
Section Cited

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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement has not been met as evidenced by:
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Based on Observation, the Licensee failed to ensure the physical plant of the facility is kept clean, safe and sanitary with the following: Large amount of debris in the back yard, including satelite dish, water heater, exercise equipment, old mattress.This debriis is a potential risk to the clients.
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2021


LIC809 (FAS) - (06/04)
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