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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700507
Report Date: 04/04/2024
Date Signed: 04/04/2024 04:44:22 PM


Document Has Been Signed on 04/04/2024 04:44 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:LEXIE RAE'S CARE HOMEFACILITY NUMBER:
342700507
ADMINISTRATOR:RODRIGUEZ, ANNIE LYNFACILITY TYPE:
740
ADDRESS:8818 SHARKEY AVETELEPHONE:
(916) 714-0853
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
04/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Annie Lyn RodgriguezTIME COMPLETED:
04:30 PM
NARRATIVE
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On 4/4/24 at 10am Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced annual required visit. LPA initially met with a staff on duty and explained the purpose of today's visit. The facility Administrator, Annie Lyn Rodriguez, arrived shortly after. Present during this visit, there were five residents in care with one staff on duty.

At 10:15am, LPA and Administrator inspected the facility’s physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathroom, 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 at this time. Outside of the facility was observed to be clean and clear of obstructions. Additionally, LPA observed outdoor furniture for clients’ use. During the inspection outside, LPA observed the side gate door to require force to open. LPA also observed the bolt securing the gate to the wall of the house was damaged causing the door to be stuck. Per interview, the door was damaged by ambulance personnel. Per Administrator, they will have it repair. Other entrances, exits and hallways were observed to be clear of obstructions. LPA observed three (3) resident bedrooms (all shared), and two (2) bathrooms for resident use. There is one staff room in the facility. 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. Bathroom is observed to be 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 residents 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 75 degrees F. Water temperature in the bathroom was measured at 107 degrees F. One fire extinguisher was last serviced on 3/12/24. Smoke detectors/ carbon monoxide combo were tested and found to be operable during this visit.

{Con't to LIC809-C}

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
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 10


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: LEXIE RAE'S CARE HOME
FACILITY NUMBER: 342700507
VISIT DATE: 04/04/2024
NARRATIVE
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Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed for accuracy for two residents. 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 resident use. LPA observed sufficient equipment and supplies to meet activity program needs of residents in care. During this visit, one resident was watching TV in the common area. Other residents were in their bedrooms.

During this inspection, LPA conducted an audit of facility files, five (5) resident files, and four (4) staff files for regulatory compliance. All four staff have criminal background clearances and are associated to this facility. All four staff files reviewed contained required contents including health screening, TB results, current first aid/CPR, and initial and ongoing required training. During resident file review, LPA discovered that 1 of 5 resident file does not contain the following required forms: admission agreement and pre-admission appraisal. Further review of resident files revealed that 1 of 5 resident have a restricted health condition. Additional review revealed that facility does not have a plan of care and staff training was not completed prior to working with the resident with restricted health condition.

Facility’s liability insurance is current per regulatory requirements. LPA reviewed facility’s disaster plan to ensure regulatory compliance. LPA observed that facility conducts quarterly fire drills. LPA was provided updated copy of LIC 308, LIC 500, 1 and liability insurance.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.



An exit interview was conducted with Administrator Annie Lyn Rodriguez, and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 04/04/2024 04:44 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: LEXIE RAE'S CARE HOME
FACILITY NUMBER: 342700507

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87616(b)
Exceptions for Health Conditions
(b) Written requests shall include, but are not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did not comply with the section cited above. It was discovered during record review that 1 of 5 residents was admitted to the facility with a restricted health condition and that licensee did not submit an exception request to the Department for approval. Furthermore, licensee did not ensure staff were trained by a licensed professional prior to working with said resident. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Licensee to submit a letter of acknowledgement and understanding of the regulation cited above to the Department by the POC due date.
Licensee to submit a request for exception to the Department for approval by the 4/11/24.
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) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 10


Document Has Been Signed on 04/04/2024 04:44 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: LEXIE RAE'S CARE HOME
FACILITY NUMBER: 342700507

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. During record review, it was discovered that 1 of 5 resident file does not contain admission agreeement and pre-admission appraisal. Per interview, these documents were not completed prior to admission. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2024
Plan of Correction
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Licensee to submit a letter of acknowledgement and understanding of the regulation cited above to the Department by the POC due date.
Type B
Section Cited
HSC
1569.39(b)
Regulations
(b) A residential care facility for the elderly that accepts or retains residents with restricted health conditions, as defined by the department, shall ensure that residents receive medical care as prescribed by the resident’s physician and contained in the resident’s service plan by appropriately skilled professionals acting within their scope of practice. An appropriately skilled professional may not be required when the resident is providing self-care, as defined by the department, and there is documentation in the resident’s service plan that the resident is capable of providing self-care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, he licensee did not comply with the section cited. 1 of 5 resident was admitted with a restricted health condition, however, the licensee did not have a plan of care in place and that staff training was completed prior to providing care to resident. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2024
Plan of Correction
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Licensee to submit a letter of acknowledgement and understanding of the regulation cited above to the Department by the POC due date.
Licensee to obtain a care plan from home health agency and submit the care plan to the Department by the POC due date.
Licensee to submit staff training related to the restricted health condition of said resident to the Department by the POC due date.
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) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 10