342700631-9-28-2023-27-AS-JFAN-CW4SN8-20230928140108

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700631
Report Date: 09/28/2023
Date Signed: 09/28/2023 02:01:18 PM

Document Has Been Signed on 09/28/2023 02:01 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	BLESSED HOME FOR SENIORS IV		FACILITY NUMBER:	342700631
ADMINISTRATOR:	GATCHALIAN, AIDA		FACILITY TYPE:	740
ADDRESS:	9771 ROEDELL WAY		TELEPHONE:	(916) 793-9941
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 6	DATE:	09/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Ma Magonlia Tolon		TIME COMPLETED:	02:30 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	On 9/28/23 at approximately 9:40am Licensing Program Analyst (LPA) Jennifer Fain arrived at this facility unannounced to conduct an annual inspection visit. LPA met with Ma Magnolia Tolon and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility has 6 bedrooms and 3 bathrooms for resident use. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 6 non ambulatory residents. LPA observed the window in the common tv area was missing its screen. Facility Observation: Upon entry the residents were watching tv in their rooms, sitting at the kitchen table visiting and looking at advertisement sheets from the newspaper. 1 resident was in isolation due to covid (day 5, testing negative.) During this inspection 6of 6 resident files and 2 of 6 staffing files were reviewed for regulatory compliance. Staff files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility has 1 resident with 1/2 bedrails and physician orders in place. LPA noted one resident with dementia could not safely manage personal grooming and hygiene items. LPA observed personal hygiene items throughout the residence including but not limited to resident rooms, bathrooms and common areas.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer Fain	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLESSED HOME FOR SENIORS IV	FACILITY NUMBER: 342700631
	VISIT DATE: 09/28/2023

NARRATIVE

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Water temperature in common bathroom reads 117.1*F which is within the regulated temperature range of 105*F to 120*. Temperature on the heating and air unit read 73*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were tested and in working order. Fire extinguisher was checked 9/8/23. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. First aid kit was observed to have adequate supplies and was accessible to staff. Facility does not contain any bodies of water. Facility’s liability insurance is current and up to date per regulatory requirements. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills.

LPA requested and received updated copies of LIC 308, LIC 500, LIC 309, LIC610E and Liability Insurance. LPA was also provided updated Infection Control Plan for CCLD files.

The facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Ma Magnolia Tolon and a copy of the LIC 809 reports, LIC 809-D pages, and Appeals rights were provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer Fain	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2023 02:01 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLESSED HOME FOR SENIORS IV	FACILITY NUMBER: 342700631
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(g)(1)

… residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. (1) Evidence means documentation from the resident’s physician that the resident is at risk if allowed direct access to personal grooming and hygiene items. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and file review, the licensee did not ensure personal grooming and hygiene items were locked and inaccessible to 1 of 6 residents in care with dementia, which poses a potential Health, Safety or, Personal Rights risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Licensee states all personal care products will be moved to locked storage areas or cabinets inaccessible to residents in care. Licensee will send an attestation that POC was completed by POC date. Proof of correction will be emailed to LPA Fain at jennifer.fain@dss.ca.gov

Type B

Section Cited

CCR

87303(c)

All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the window screen in the common area was missing, which poses an immediate Health, Safety or, Personal Rights risk to persons in care.
	POC Due Date: 10/27/2023
	Plan of Correction
1 2 3 4	Licensee will replace missing screen and send proof of correction to LPA Fain by 10/27/23 at jennifer.fain@dss.ca.gov

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer Fain	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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