<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700531
Report Date: 06/22/2023
Date Signed: 06/22/2023 05:38:44 PM


Document Has Been Signed on 06/22/2023 05:38 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:A1 MAGNIFICENT HOMEFACILITY NUMBER:
342700531
ADMINISTRATOR:GAERLAN, LEONIDAFACILITY TYPE:
740
ADDRESS:3311 MISSION AVENUETELEPHONE:
(916) 335-5831
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:5CENSUS: 2DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:caregiverTIME COMPLETED:
05:40 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) Kevin Mknelly arrived at the facility unannounced on 6/22/23 to conduct a Required-1 Year Inspection utilizing the CARE inspection tool. LPA met with Caregiver and explained the purpose of the visit . Administrator notified and arrived to assist.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA advised that the sliding screen door to R2's bedroom be repaired. Kitchen locks were repaired or items relocated.

LPA reviewed 2 resident files and 1 staff files. LPA found an incomplete file for R1- more training needed, transfer request has been submitted.

Infection control plan is not present.

Licensee will submit a copy of liability insurance.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with licensee . Copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
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 4


Document Has Been Signed on 06/22/2023 05:38 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: A1 MAGNIFICENT HOME
FACILITY NUMBER: 342700531

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review found no plan, the licensee did not comply with the section cited above in the absence of an approved plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2023
Plan of Correction
1
2
3
4
Licensee will submit a Infection control for approval by the POC date of 7/13/23
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
1
2
3
4
Based on records review, the licensee did not comply with the section cited above in R's records were found to contain all required training and a completed transfer request which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/06/2023
Plan of Correction
1
2
3
4
Licensee will submit proof of R1's required training by the POC date of 7/6/23
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 SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4