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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700309
Report Date: 07/15/2024
Date Signed: 07/17/2024 10:04:47 AM


Document Has Been Signed on 07/17/2024 10:04 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:D&T LIVING SOLUTION HOME CAREFACILITY NUMBER:
342700309
ADMINISTRATOR:SAVENCO, TATIANAFACILITY TYPE:
740
ADDRESS:2829 PANAY CTTELEPHONE:
(916) 417-6264
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
07/15/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Marva Grant, caregiver and Olga KostiuechenkoTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to conduct a Required annual Inspection. LPA met with caregiver staff, Marva Grant, and Olga Kostiuechenko. LPA spoke to the Administrator, by phone, who stated she was not able to be at the facility at this time and authorized staff, Marva Grant, to sign today's report. LPA observed (3) residents present in the common area and (3) residents in their rooms. Currently, there is (1) resident on hospice. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver approved for (6) residents.

LPA and staff toured the interior/exterior of the facility including common areas, (6) private resident bedrooms, (2) resident bathrooms, staff rooms, kitchen, laundry area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed each bathroom to have the necessary grab bars, non-skid flooring, shower chair, paper towels, trash can with lid and 20-second hand-washing poster. Medications are locked in a designated closet, and all toxins are locked in the laundry area. The inside temperature measured 71*F and the hot water measured 110*F in the kitchen. LPA observed 2+ day perishable and 7+ day non-perishable supply of food. Sharps are locked in the kitchen Smoke/monoxide alarms are working and the fire extinguisher was last serviced 5/7//24. Quarterly fire drills are conducted. There are non-audio camera in the common areas. Outside, there is a patio table with chairs and a cover, and the landscape is finished. There are three open, unlocked exits where residents/staff can evacuate.

LPA reviewed (3) resident files and found paperwork to be organized and current. Medications were reviewed for (1) resident. Orders matched medications being administered. LPA reviewed staff files for (2) staff. Both staff are cleared/associated and have completed all required training in the last 12 months and have current First Aid/CPR certifications.

LPA requested an updated copy of LIC500, LIC308 and current liability insurance be provided to the Department by 7/22/24. Exit interview. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 07/17/2024 10:04 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: D&T LIVING SOLUTION HOME CARE
FACILITY NUMBER: 342700309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)(A-F)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
(A) The name of the resident for whom prescribed.
(B) The name of the prescribing physician.
(C) The drug name, strength and quantity.
(D) The date filled.
(E) The prescription number and the name of the issuing pharmacy.
(F) Instructions, if any, regarding control and custody of the medication.






This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in (1) out of (1) documents (LIC622) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Licensee/Administrator agree to begin keeping a record of all centrally stored medications, including documenting when name, prescription number, date the medication is received, started, etc. The LIC622 (Centrally Stored Medication Record) may be used. Documentation that a medication record has been started for July 202, for each resident, and columns have been completed on the LIC622. A copy to be provided to the Department for each resident by 7/31/24.
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/17/2024 10:04 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: D&T LIVING SOLUTION HOME CARE
FACILITY NUMBER: 342700309

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)(A-F)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
(A) The name of the resident for whom prescribed.
(B) The name of the prescribing physician.
(C) The drug name, strength and quantity.
(D) The date filled.
(E) The prescription number and the name of the issuing pharmacy.
(F) Instructions, if any, regarding control and custody of the medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and (record review, the licensee did not comply with the section cited above in (1) out of (1) medication record which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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2
3
4
Licensee/Administrator agree to begin a medication record (LIC622) for each resident to document when a medication is received, started, refilled, destroyed, etc. LIC622 to be provided for each resident to the Department by 7/31/24 for the month of July 2024.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
LIC809 (FAS) - (06/04)
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