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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 01:19:05 PM


Document Has Been Signed on 03/20/2024 01:19 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director -Stephen Macdonald TIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced on 03/20/24 to conduct a case management inspection to follow up on a recent AWOL for residents, R1 and R2 at the facility. LPAs met with Executive Director (ED), Stephan Mcdonald and explained the purpose of the visit.

R1’s AWOL Incident (1) - The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 03/05/24 regarding resident (R1) for date 02/26/24. Facility indicated R1 was at Winco around 3pm when R1 had change in condition which resulted in Winco staff calling EMS services. R1 was transferred to a local hospital and received medical care. R1 returned to the facility on the same day with no change. It is noted that Winco is 0.2 miles from the facility and is located across a busy street. The incident report and LIC602 (dated-07/19/21) were reviewed for R1 and it was discovered R1 has diagnosis of dementia and cannot leave the facility unassisted. The incident report submitted to the Department did not indicate that R1 was AWOL, only that EMS services were sought while R1 was out of the community.

R2’s AWOL Incident (1)- Based on information provided by the facility, it was learned that R2 was at Winco with R1 on 02/26/2024. A review of R2’s physician report (LIC602, dated- 11/07/23 stated R2 has a diagnosed of dementia and cannot leave facility unassisted as well. The facility did not submit an incident report for R2’s AWOL.

Although no injuries resulted from R1 and R2s AWOL incident on 02/26/24, R1 and R2s LIC602s indicate they were unable to leave the facility unassisted. Facility staff did not provide care and supervision to R1 and R2 resulting in R1and R2 leaving the facility unassisted. It has been determined that the facility did not report R1 and R2s AWOL on 02/26/24 therefore did not meet mandatory reporting requirements. In addition, record review indicated that facility does not has updated medical assessment for R1, who has a diagnosis of dementia. R1’s last LIC602 was dated 07/19/21. Based on Title 22 regulations, a resident with a diagnosis of Dementia shall have an updated medical assessment at least annually.

Violations are cited today per California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies issued are noted on the LIC809D. Immediate Civil penalties of $250.00 were assessed on LIC421FC today due to repeat violations of the same regulations within 12 months for Regulation 87411 and Regulation 87211. Exit interview conducted. Copy of report, appeal rights has been provided to ED.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (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)
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Document Has Been Signed on 03/20/2024 01:19 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2024
Section Cited
CCR
87411

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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by;
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Licensee/administrator will send statement of understating of regulation 87411 and will do staff training regarding providing care and supervision to residents per their needs and service plan. All these documents shall be submitted to department by POC date-03/21/24.
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Based on information of the incident for R1 and R2, R1 and R2, AWOL from the facility on 02/26/24. This poses a immediate risk to the health and safety of residents in care.
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Type B
04/05/2024
Section Cited
CCR87211(a)(D)

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87211-Reporting Requirements(a) (D)- (a) Each licensee shall furnish to the licensing agency such reports as the Department….(D) Any incident which threatens the welfare, safety or health of any resident,…… unexplained absence of any resident…..This requirement is not met as evidenced by;
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Licensee/administrator will send statement of understating of regulation 87211 and will do staff training regarding reporting requirements as required by this regulation. All these documents shall be submitted to department by POC date-04/05/24.
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Based on records review,it has been observed that facility did not report R1 and R2s AWOL incident for 02/26/24 to department as required which poses potential health and safety risks for residents in care.
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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: Talwinder BainsTELEPHONE: (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 01:19 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2024
Section Cited
CCR
87705(c)(5)

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87705-Care of Persons with Dementia-
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually.. this requirement is not met as evidence by;
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Licensee/administartor shall complete medical assesment (LIC602) and
re-appraisal for resident R1 as required and will send proof to department once completed. All POC documents are due by 04/05/24.
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Record review and gathered information indicated that facility does not have updated Medical Assesment (LIC602) and Re-appriasal completed for R1 as required which poses a potenial risk to health and safety for residents in care.
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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: Talwinder BainsTELEPHONE: (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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