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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700355
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:21:00 PM

Document Has Been Signed on 12/21/2023 03:21 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:
12/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Hayat HassenTIME COMPLETED:
03:30 PM
NARRATIVE
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On 12/21/2023, at 2:15pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management visit. LPA met with the facility assistant administrator/direct care staff, Hayat Hassen, and explained the purpose of the visit. The administrator was informed of the visit and gave permission for Hayat to sign this report. During this visit, present were three (3) clients in care with two (2) staff on duty.

This visit is to cite deficiencies as noted during a Title 17 Monitoring Review conducted on 10/30/2023 by Alta California Regional Center (ACRC) representatives. The Department was made aware that a medication error was found substantiated during a medication review. ACRC representatives noted the absence of staff signatures on 3 of 3 clients’ Medication Administration Record (MAR) from October 29, 2023, to the morning dose on October 30, 2023.

Based on documentation review, the facility has complied with the correction plan noted in the Title 17 Monitoring Review report by the stated deadlines of 11/20/2023, 11/27/2023, 12/4/2023, and 12/11/2023.

Based on LPA’s observations and interview with the facility administrator, the preponderance of evidence standards has been met.

Per California Code of Regulations, Title 22 Division 6, deficiencies are being cited during this visit.

If any deficiencies are not corrected by the noted due dates, civil penalties may be assessed.

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

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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 12/21/2023 03:21 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 12/21/2023 at 02:54 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KAMIL HASSEN CARE HOME
FACILITY NUMBER: 342700355

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/21/2023
Section Cited
CCR
80075(b)

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80075 Health Related Services: (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
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Licensee has submitted proof of a double check systerm to regional center to ensure all medications are administered correctly and MAR signed appropriately.

POC Cleared prior to today’s visit
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Based on interview and record review, the licensee did not comply with the section cited above as during a Title 17 monitoring review, it was reported in 3 of 3 clients medication administration record that staff signatures were absent from 10/29/23 to morning of 10/30/23 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: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


LIC809 (FAS) - (06/04)
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