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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700525
Report Date: 05/23/2024
Date Signed: 05/23/2024 10:37:47 AM


Document Has Been Signed on 05/23/2024 10:37 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 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: 108DATE:
05/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Stephen MacDonaldTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/23/24 to do case management visit for Residents, R1 and R2 . LPA met with administrator Stephen Macdonald and explained the purpose of the visit.

Incident for R1- Department followed up on Incident Report and SOC 341 sent by facility on 04/19/24 for an incident that occurred on 04/18/24 regarding resident, R1. Department conducted record review and interviews regarding this incident which occurred on 04/18/24 around 10.30 pm. Based on information gathered, it has been concluded that R1 advised staff they were not ready to lay down to go to bed however staff assisted R1 to their bed without R1’s consent which was a violation of Resident’s Rights per CCR, Title 22 Regulation, therefore Citation-A has been issued during this visit.

Incident for R2- The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 05/09/24 regarding resident (R2) leaving the facility (AWOL) unattended on 05/08/24 at approximately 07:30 pm. Per incident report, it was discovered that R2 exited from main lobby door and was outside for approximately 3 minutes. IR indicated that R2 was wearing a wander guard at time of incident which alerted staff that R2 left the premises. R2 was brought back to the facility by staff uninjured. Facility notified R2’s doctor and family regarding this AWOL incident. R2's physician's report (LIC602) dated 04/26/24 indicates that resident has diagnosis of dementia and cannot leave the facility unassisted. Although no injuries resulted from R2’s AWOL, R2 was unable to leave the facility unassisted. Facility staff did not provide care and supervision to R2 resulting in R2 leaving the facility unassisted. 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.

Deficiencies issued are noted on the LIC809D per Title 22 Regulations.

Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted. Appeal rights were provided and copy of the report was provided.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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 2


Document Has Been Signed on 05/23/2024 10:37 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ALMOND HEIGHTS
FACILITY NUMBER: 342700525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2024
Section Cited
CCR
87468.1(a)(1)

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87468.1-Personal Rights of Residents in All Facilities- (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidence by;
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Administrator shall submit letter of understanding regarding Regulation-87468 and shall conduct all staff training to go over Residents Personal Rights and send all these documents to CCL by POC date-05/24/24.
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Record review and interviews conducted indicated that staff assisted R1 to their bed on 04/18/24 without their consent which poses an immediate risk to the health and safety of residents in care.
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Type A
05/24/2024
Section Cited
CCR87411

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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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Administrator shall conduct staff training regarding AWOL risk residents twice a month till July 2024 and will send training documents to CCL. Outline of training shall be send to CCL by 05/24/24.
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Based on records of the incidents for R2, it was concluded that R2 was able AWOL from the facility unassisted on 05/08/24 which poses an immediate risk to the health and safety of 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: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2