342700400-2-11-2025-27-AS-PLEE-DDSQPT-20250211112117

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700400
Report Date: 02/11/2025
Date Signed: 02/11/2025 11:21:25 AM

Document Has Been Signed on 02/11/2025 11:21 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 HOME		FACILITY NUMBER:	342700400
ADMINISTRATOR/ DIRECTOR:	ROODENBURG, FRANS		FACILITY TYPE:	740
ADDRESS:	3105 HEMPSTEAD RD		TELEPHONE:	(916) 485-7420
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95864
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	02/11/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:32 AM
MET WITH:	Milagros Dioso		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 02/11/25 at 8:32 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA met with Licensee Milagros Dioso. LPA explained the purpose of the visit. Licensee assisted with today’s visit. Licensee’s administrator certificate # is 7014091740 and will expire on 11/21/25. The current census is 4 with 3 facility staff. This facility is a single story building licensed to serve six (6) non-ambulatory residents and approved for 2 hospice residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 108.5 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 01/13/25. The last fire drill was conducted on 12/05/24. LPA observed the facility has a has a public telephone in the common room and the facility has the required posters posted. Facility thermostat observed at 72 degrees Fahrenheit. LPA observed toxins located in the kitchen cabinet and kept locked and inaccessible to residents. LPA observed sharp knives kept locked and inaccessible to residents. LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed residents’ medications and medication administration record (MAR) and it was incomplete. Continued LIC 809-C

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Pang Lee	TELEPHONE: (916) 508-9726
	DATE: 02/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025

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 02/11/2025 11:21 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: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and records review the licensee did not comply with the section cited above. Licensee who is the direct caretaker did not have at least 20 hours of continuing education. This poses/posed a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 02/21/2025
	Plan of Correction
1 2 3 4	Licensee will ensure that all facility staff have at least 20 hours of continuing education. Licensee will read the regulation cited and provide LPA Lee a statement of acknowledgement of understanding the regulation cited. POC will be email to LPA Lee by POC date 02/21/25 end of day 5:00 PM.

Type B

Section Cited

CCR

87465(c)(3)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, records review and observation the licensee did not comply with the section cited above. It was observed that residents’ medications from 02/10/25 PM pass and this morning medication 8:00 AM pass was not initialed. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2025
	Plan of Correction
1 2 3 4	Licensee will ensure that all residents medications are initialed after each medication pass. Licensee will read the regulation cited and provide LPA Lee a statement of acknowledgement of understanding the regulation cited. POC will be email to LPA Lee by POC date 02/21/25 end of day 5:00 PM.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Pang Lee	TELEPHONE: (916) 508-9726
	DATE: 02/11/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 02/11/2025

NARRATIVE

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It was observed that residents’ medications from 02/10/25 PM pass and this morning medication 8:00 AM pass was not initialed. The first aid kit was checked and contained the required components. LPA requested resident and staff files for review. LPA reviewed 4 out of 4 resident files and they were complete. LPA reviewed 2 staff files and 1 out of 2 staff files were complete. It was observed that the licensee didn’t have at least 20 hours of continuing education. LPA was also informed by the licensee that she is the direct caregiver to the residents. LPA reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents will be email to LPA Lee by 02/18/25 end of day 5:00 PM
(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025

LIC809 (FAS) - (06/04)

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