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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700638
Report Date: 05/04/2023
Date Signed: 05/04/2023 12:58:34 PM


Document Has Been Signed on 05/04/2023 12:58 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:ESTHER CARE HOMEFACILITY NUMBER:
342700638
ADMINISTRATOR:EGUAVOEN, CHARLESFACILITY TYPE:
740
ADDRESS:4415 ROLLINGROCK WAYTELEPHONE:
(916) 560-3800
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 3DATE:
05/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:CHARLES EGUAVOENTIME COMPLETED:
02:00 PM
NARRATIVE
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On 5/4/2023, Licensing Program Analysts (LPA) Cassie Yang arrived at the facility unannounced to conduct a case management visit regarding an incident report the Department received on 5/3/2023. LPA met with caregiver, Tarachin Elliot, and explained the purpose of the visit. Caregiver then contacted Administrator (Admin), Charles Eguavoen, who arrived to the facility shortly afterwards.

The facility is currently licensed for (6) non-ambulatory, hospice waiver of 2. During today's visit, there are (3) residents, and no residents on hospice services.

At LPA's arrival, LPA observed the fire door on the right wing to be propped open with a door stopper from the bottom. LPA observed caregiver removing it prior to Admin's arrival.

During today's visit, LPA and Admin discussed the importance of contacting emergency medical services when a resident is injured and/or falls.

Additionally, LPA provided Admin a copy of CCR 87203 Fire Safety.

As a result of today's inspection, deficiencies were cited. Civil penalty assessed. Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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 2


Document Has Been Signed on 05/04/2023 12:58 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: ESTHER CARE HOME
FACILITY NUMBER: 342700638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2023
Section Cited

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. This requirement is not met as evidenced by:
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Licensee agrees to provide training for all direct care staff on the requirement to seek medical attention timely for residents.
Licensee will schedule the training and provide CCL with the training content and signed staff attendance sheet as proof of correction by 5/5/2023.
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Based on record review and interview, Licensee did not ensure residents in care received medical attention in a timely manner as LPA was informed R1 fell at 3:35 AM and dislclosed her back hurts, but was not sent to the emergency room until approximately 7:15AM, which poses an immediately risk to the residents in care.
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Type A
05/05/2023
Section Cited

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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
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LPA observed caregiver removing the door stop and closed the door immediately.
Licensee is to notify all staff that the fire door must remain closed at all time.
Licensee is to submit a letter of compliance of CCR 87203 to CCL by 5/5/2023.
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Based on observation, Licensee did not ensure facility was in compliance as LPA observed the fire door located on the right wing to be propped open with a door stopper, which poses an immediate risk to the residents in care.
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***$500.00 Immediate Civil Penalties issued today.
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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
LIC809 (FAS) - (06/04)
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