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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700355
Report Date: 12/06/2023
Date Signed: 12/06/2023 12:22:19 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/06/2023 12:22 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:KAMIL HASSEN CARE HOMEFACILITY NUMBER:
342700355
ADMINISTRATOR:HASSEN, FOZIAFACILITY TYPE:
735
ADDRESS:8705 SUMMER POINTE DRTELEPHONE:
(916) 425-4622
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 3DATE:
12/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Fozai HassenTIME COMPLETED:
12:30 PM
NARRATIVE
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On 12/6/23 at 9:30am Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced annual required visit. LPA met with the facility administrator, Fozai Hassen, and explained the purpose of today’s visit. The facility is currently licensed to serve 4 developmentally and intellectually disabled adults. Present during this visit, there were two (2) clients in care with two (2) staff on duty.

At 9:45am, LPA inspected the facility’s physical plant including but not limited to the kitchen, dining room, client bedrooms, client bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. The facility is a one-story structure located in a residential neighborhood. There were no bodies of water on the premises. Outside of the facility was observed to be clean and clear of obstructions. Additionally, LPA observed outdoor furniture for clients’ use and covered area for outdoor activities. LPA observed two (2) windows in bedroom 4 were missing of window screens. Entrance, exits and hallways were observed to be clear of obstructions. LPA observed four (4) client bedrooms, two (2) bathrooms for client use, office room and staff room. LPA observed beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage for the client’s personal belongings. Bed linens, comforters, and bath towels were adequately stocked during the visit. The client rooms were inspected: bedrooms 1, 3, and 4 are currently occupied and bedroom 2 is currently empty. Bathrooms were operational and adequately supplied, including with grab bars and non-skid flooring.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were locked and not accessible to clients in care. The kitchen was inspected, and sufficient 2-day perishable and 7-day non-perishable food was maintained adequately. Room temperature was maintained in the facility at 72 degrees F. Water temperature in one of the bathrooms located inside bedroom 4 was initially measured at 125.8 degrees F. Administrator was observed to adjust the water heater to lower the water temperature. Second water readings in both bathrooms after the adjustment were measured between 105- and 120-degrees F. Per interview with the administrator, it was determined that staff do not keep record of hot water temperature readings and that the water temperature is checked once in a while. Fire extinguisher was serviced on 7/19/23. Smoke detectors and carbon monoxide were tested and found to be operable during this visit. Per administrator, facility has smoke detectors/carbon monoxide monitor combination.

{Con't to LIC809-C}

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KAMIL HASSEN CARE HOME
FACILITY NUMBER: 342700355
VISIT DATE: 12/06/2023
NARRATIVE
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Medication storage area was observed to be locked and inaccessible to clients in care. Medications were reviewed for accuracy. First aid kit was observed to have adequate supplies and accessible to staff. The facility maintains for each client Centrally Stored Medication, Destruction Record and PRN Log. LPA observed the facility's infection control practices. All mandated inspection control posters were posted. LPA observed personal rights poster. Facility has appropriate internet access available for client use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of clients in care.

During this inspection, LPA conducted an audit of facility files, three (3) client files, and six (6) staff files for regulatory compliance. All staff noted on LIC 500 have criminal background clearances and are associated to this facility. LPA completed 1 staff interview. All client files reviewed contained all required contents including admission agreements, medical assessments, and individual program plan (IPP). All staff files reviewed contained required contents including health screening, TB results, current first aid/CPR, and initial and ongoing required trainings. Facility’s liability insurance is current per regulatory requirements. LPA reviewed facility’s disaster plan to ensure regulatory compliance. LPA observed that facility conducts monthly fire drills. LPA requested an updated copy of LIC 308, LIC 500, facility sketch, current staff schedule, surety bond and liability insurance.

Per California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).


The following deficiencies were observed during today’s inspection:

• During facility observation, LPA observed two (2) windows in bedroom #4 were missing window screens.


• Hot water temperature for the bathroom in bedroom #4 was measured at 125.8 degrees F.

An exit interview was held with Fozai Hassen, administrator, and a copy of this report and appeal rights were provided to the facility.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/06/2023 12:22 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 12/06/2023 at 11:52 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KAMIL HASSEN CARE HOME
FACILITY NUMBER: 342700355

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2023
Section Cited
CCR
80088(e)(1)

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(e) Faucets used by clients...(1)...attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
This requirement is not met by:
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Corrected during the visit. The facility Administrator was observed to adjust the hot water heater. Second reading was measured between 105 and 120 degrees F in both bathrooms.
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Based on observation, the licensee did not comply with the section cited above in [1] out of [2] facility restroom faucets delivering hot water was measured at 125.8 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
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Administrator to keep a log of hot water temparature reading moving forward.
Type B
12/13/2023
Section Cited
CCR80088(b)

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(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met by:
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Licensee to install window screens to the two windows in bedroom 4. A statement of correction, along with pictures of replaced window screen will be completed and submitted into CCL by the POC due date.
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Based on observation, the licensee did not comply with the section cited above where two (2) windows in bedroom #4 were missing window screens which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
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