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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700554
Report Date:
10/24/2023
Date Signed:
10/26/2023 09:05:26 AM
Document Has Been Signed on
10/26/2023 09:05 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:
ANGIES CARE HOME
FACILITY NUMBER:
342700554
ADMINISTRATOR:
CRUDO, ANGELINA
FACILITY TYPE:
740
ADDRESS:
8558 SHERATON DR
TELEPHONE:
(916) 962-2460
CITY:
FAIR OAKS
STATE:
CA
ZIP CODE:
95628
CAPACITY:
6
CENSUS:
6
DATE:
10/24/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:30 AM
MET WITH:
Angelena Crudo
TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 10/24/23 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with Caregiver and explained the purpose of the visit. Administrator was 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 the following issued were discussed and plans of correction established: Construction to the backyard and obstruction to several resident rooms fire exits are not currently usable. LPA contacted the fire department for direction. Return contact pending. Resident use faucet was measured at 122'F. Licensee will adjust and monitor water temperatures. A recently moved in caregiver does not yet have reasonable accommodations. Licensee to make arrangements. Medication storage is disorganized. Licensee will reorganize medication area.
LPA reviewed resident files. 6 of 6 Files are incomplete for various required forms.
LPA reviewed staff files.2 of 2 files are incomplete for forms and training.
As a result of this inspection, the following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
Exit interview conducted. Report provided.
SUPERVISOR'S NAME:
Maribeth Senty
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Kevin Mknelly
TELEPHONE:
(209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE:
10/24/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
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Document Has Been Signed on
10/26/2023 09:05 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:
ANGIES CARE HOME
FACILITY NUMBER:
342700554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observations and interviews, the licensee did not comply with the section cited above in exterior doors for non-ambulatory rooms are non-operational due to outdoor constrction or room obstructions which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/30/2023
Plan of Correction
1
2
3
4
LPA contactedl fire authoity tonotify them of need for an inspection.
Licensee will report to CCL for when the fire marshal inspection isis speduled.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:
Maribeth Senty
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Kevin Mknelly
TELEPHONE:
(209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE:
10/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/24/2023
LIC809
(FAS) - (06/04)
Page:
2
of
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Document Has Been Signed on
10/26/2023 09:05 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:
ANGIES CARE HOME
FACILITY NUMBER:
342700554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
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 2 out of 2 staff not having health screens on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/14/2023
Plan of Correction
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2
3
4
Licensee will sumit proof of health screen and TB testing for S1 and S2 by the POC date of 11/14/23
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 Senty
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Kevin Mknelly
TELEPHONE:
(209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE:
10/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/24/2023
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
10/26/2023 09:05 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:
ANGIES CARE HOME
FACILITY NUMBER:
342700554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(b)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following:
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 2 of 2 staff files to lack required records and training docuentation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/14/2023
Plan of Correction
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2
3
4
Licensee will complete staff files for all required documents.
To be cleared by POC visit.
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and interview, the licensee did not comply with the section cited above in S1, who was present while licensee was not, does not have med training but was responsible for med dispensing. This posed a potential risk to residents
POC Due Date:
10/27/2023
Plan of Correction
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2
3
4
Proof of S1 medication training to be submitted by POC date of 10/27/23.
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 Senty
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Kevin Mknelly
TELEPHONE:
(209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE:
10/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/24/2023
LIC809
(FAS) - (06/04)
Page:
4
of
5
Document Has Been Signed on
10/26/2023 09:05 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:
ANGIES CARE HOME
FACILITY NUMBER:
342700554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.
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 [count] out of 3 of 6 residents did not have pre-appraisals on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/14/2023
Plan of Correction
1
2
3
4
Resident reappraisals will be created.
POC to be cleared by visit.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:
Maribeth Senty
TELEPHONE:
(916) 263-4813
LICENSING EVALUATOR NAME:
Kevin Mknelly
TELEPHONE:
(209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE:
10/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/24/2023
LIC809
(FAS) - (06/04)
Page:
5
of
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