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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700400
Report Date: 01/29/2024
Date Signed: 01/29/2024 11:32:03 AM


Document Has Been Signed on 01/29/2024 11:32 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:HEMPSTEAD HOMEFACILITY NUMBER:
342700400
ADMINISTRATOR:ROODENBURG, FRANSFACILITY TYPE:
740
ADDRESS:3105 HEMPSTEAD RDTELEPHONE:
(916) 485-7420
CITY:SACRAMENTOSTATE: CAZIP CODE:
95864
CAPACITY:6CENSUS: 5DATE:
01/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Milagros DiosoTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with licensee Milagros Dioso and explained the purpose of the visit.

LPA Moleski reviewed three resident files (R1-R3) and four staff files (S1-S4). S4 did not have a health screening. Dioso said S4 was a volunteer.

LPA Moleski toured the facility with Dioso and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 100 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed locked cabinets for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed one staff member (S2) and two residents (R2, R4).

This facility is being cited per 22 CCR Sections 87303(e)(2) and 87412(b)(2). An exit interview was held with Dioso. Appeal rights and a copy of this report was left with Dioso.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
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 01/29/2024 11:32 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: HEMPSTEAD HOME
FACILITY NUMBER: 342700400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(b)(2)
"(b) Personnel records shall be maintained for all volunteers and shall contain the following:

(2) Health screening documents as specified in Section 87411(f)."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not ensure a volunteer received a health screening, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2024
Plan of Correction
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Licensee agrees to acquire a health screening for S4 and to email LPA Moleski a copy of the health screening by the POC due date.
vincent.moleski@dss.ca.gov
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/29/2024 11:32 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: HEMPSTEAD HOME
FACILITY NUMBER: 342700400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure water temperature was maintained at a minimum of 105 degrees Fahrenheit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2024
Plan of Correction
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Licensee agrees to raise the water temperature to meet the required range. LPA Moleski will return in order to re-test the water temperature.
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3