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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700525
Report Date: 03/20/2024
Date Signed: 03/20/2024 04:08:51 PM


Document Has Been Signed on 03/20/2024 04:08 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ALMOND HEIGHTSFACILITY NUMBER:
342700525
ADMINISTRATOR:MACDONALD, STEPHENFACILITY TYPE:
740
ADDRESS:8685 GREENBACK LNTELEPHONE:
(916) 542-7988
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:145CENSUS: 121DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Stephen MacDonaldTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived on 3/20/24 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (10) and staff (10) files. All residents (10) files contained the required paperwork. Medications reviewed.

LPAs and Administrator Stephen MacDonald toured the facility together to ensure the health and safety of residents in care. The areas toured included, kitchen, hallways, apartments, dining room/kitchen, and common areas. Food is within compliance. Fire drills and disaster drills reviewed. Fire extinguisher ready to be used. Smoke detector and carbon monoxide detectors are operational.

Deficiencies were observed and cited per Title 22, CCR Regulations as listed on 809-D.
Exit interview conducted. Copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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 03/20/2024 04:08 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ALMOND HEIGHTS
FACILITY NUMBER: 342700525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(1)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observatios and staff interviews for medication audit, LPA learned that R1 and R2 have medications in their rooms and they have dementia diagnosis and cannot manage their medications per physicians orders, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2024
Plan of Correction
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Facility will send a statement of understanding of this regulation and will do staff training for medication administration. All POC douments are due by 03/21/24.
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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/20/2024 04:08 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ALMOND HEIGHTS
FACILITY NUMBER: 342700525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews it has been concluded that facility does not have Personnel form (LIC 501) for 3 staff out of 10, first aid and CPR certification for 3 out of 10 staff, and Health Screening/TB for 2 out of 10 staff files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2024
Plan of Correction
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Facility will complete the Personnel form (LIC 501) for 3 staff out of 10, first aid and CPR certification for 3 out of 10 staff, and Health Screening/TB for 2 out of 10 staff files, for all staff files as required and will send proof to Department once completed. All POC documents are due by 04/15/24.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
LIC809 (FAS) - (06/04)
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