342700470-3-7-2023-59-AS-SCAA-CPPTYV-20230307140923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700470
Report Date: 03/07/2023
Date Signed: 03/07/2023 02:09:44 PM

Document Has Been Signed on 03/07/2023 02:09 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME:	ZIPPORAH CARE HOME LLC		FACILITY NUMBER:	342700470
ADMINISTRATOR:	TADDESE, GENET SOLOMON		FACILITY TYPE:	740
ADDRESS:	8223 TWIN OAKS AVE		TELEPHONE:	(916) 539-1767
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	6	CENSUS: 5	DATE:	03/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Joe Rivera, Administrator		TIME COMPLETED:	02:15 PM

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	Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the full annual care inspection tool. , LPA was greeted by Sashana Barnett, (Caregiver) and explained the purpose of the inspection. Caregiver contacted current Administrator, Gerard Rivera, and was informed he would be at the facility to assist with the visit. Administrator arrived at 11:30 am. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols, wore a surgical mask and was screened per Covid-19 precautionary measures upon entering the facility. The facility has a pending change in ownership. LPA and caregiver toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms, (1) shared resident bedroom, (2) resident bathrooms with showers, kitchen, office and outside laundry area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels -Administrator to ensure 20-second hand-washing posters are placed above each bathroom/kitchen sink. . LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food on site and locked medications nearby the kitchen. LPA observed unlocked sharps and toxins in the kitchen as the lock was not functioning. LPA observed the inside temperature to be 69F. The fire extinguisher was last serviced on 1/3/2023.. Discussed vaccination status of residents/staff and eligibility for boosters. Booster flyer provided. LPA observed multiple Covid posters throughout as well as other required postings. RCFE Administrator certificate #6061379740- ecp 12/26/23 was shown to LPA. . LPA observed (1) unlocked gate from the inside back patio, a pool that is gated and locked and an covered patio area. LPA reviewed (2) of (5) resident files and found them to contain current documentation except for a current care plan.* LPA reviewed medication orders and medications given for these same (2) residents and found no discrepancies. Facility uses an electronic Medication Administration Record (MAR). LPA reviewed staff files and found them to contain current documentation, including training and First Aid/CPR certification. cont on 809C(1)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: ZIPPORAH CARE HOME LLC	FACILITY NUMBER: 342700470
	VISIT DATE: 03/07/2023

NARRATIVE

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Administrator to print out copy of 610E for staff to refer to at all times.

Per California Code of Regulations, Title 22, The following (2) deficiencies were found and are cited on the 809D page. Failure to correct the deficiencies by the noted due date may result in a penalty(ies) being assessed.

LPA requested an updated copy of the LIC308. LIC500 and current liability insurance during today's inspection by 3/14/23.

Exit interview. Copy of report and appeal rights provided to Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/07/2023 02:09 PM - 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: ZIPPORAH CARE HOME LLC	FACILITY NUMBER: 342700470
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1-2)

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as multiple sharps and toxins were not locked in a drawer or cabinet with a working lock, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/08/2023
	Plan of Correction
1 2 3 4	Administrator agrees to install a magnetic or key lock on the drawer with sharps and on the cabinet with toxins by end of day, 3/8/23. Administrator agrees to provide a photo with the working locks to CCLD by text, email or fax.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/07/2023 02:09 PM - 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: ZIPPORAH CARE HOME LLC	FACILITY NUMBER: 342700470
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463

Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in (2) out of (2) files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/21/2023
	Plan of Correction
1 2 3 4	Administrator agrees to complete a LIC625 (or care plan) for residents (R1 and R2) by 3/21/23. Administrator agrees to ensure that all other residents also have a care plan in place that has been completed/updated within the last 12 months. Documents of updated care plans to be provided to CCLD by 3/21/23 by email or fax.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

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