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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700638
Report Date: 09/17/2024
Date Signed: 09/17/2024 02:53:23 PM


Document Has Been Signed on 09/17/2024 02:53 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: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:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:CHARLES EGUAVOENTIME COMPLETED:
03:10 PM
NARRATIVE
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On 9/17/2024, Licensing Program Analysts (LPAs) Cassie Yang and Graham Gunby arrived unannounced at the facility to conduct a required annual inspection utilizing the CARE tool. LPAs met with caregiver and explained the purpose of the visit, who then contacted Administrator who then arrived to the facility shortly afterwards.

LPAs and Administrator conducted a tour of the interior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: five residents room, one staff room, two bathrooms, kitchen and the common areas. LPAs observed medications present on S1's counter by room entrance. LPAs were informed room cannot be locked because there is no key. Medications were immediately relocated by Administrator. LPAs conducted a medication audit and found R1's tylenol to be expired, additionally, LPAs observed two medications present without a physician order on file.

File review was conducted and LPAs observed S1 to not have LIC 503 and/or negative TB result present on file. LPAs further observed R1's LIC 602A to be out of date, needing annual assessment.

Emergency Disaster Plan reviewed. LPAs informed Administrator document should be reviewed and updated annually. LPAs and Administrator discussed fire and earthquake drill are to be conducted quarterly.

A copy of CCR Title 22 87705 Care of Persons with Dementia.

As a result of today's visit, deficiencies observed. Please see LIC 809-Ds.

Exit interview and a copy of the report and appeal rights provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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 3


Document Has Been Signed on 09/17/2024 02:53 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: ESTHER CARE HOME
FACILITY NUMBER: 342700638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above as R1's LIC 602 indicated dementia but has not been reassessed in 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee is get an updated LIC602A for R1.
Licensee is to submit a statement of understanding that each resident with dementia shall have an annual medical assessment and reappraisal. POC due 10/17/2024, failure to correct by due date may be a $100 civil penalty per day until received.
Type B
Section Cited
CCR
87412(a)(11)
87412 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: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above as S1's file did not have LIC503 and/or TB testing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee is to ensure S1 gets a negative TB test.
Licensee is to submit S1's LIC 503 to LPA by due date.
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: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/17/2024 02:53 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: ESTHER CARE HOME
FACILITY NUMBER: 342700638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
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: (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication audit, the licensee did not comply with the section cited above as LPAs observed Tylenol to be expired with date of 06/14, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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Licensee is to destroy the medication and ensure there is a replacement bottle.
Licensee will submit a statement of understanding that all medication should be audited to ensure it is within best of date.
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPAs observed multiple bottles of medication in S1's room which door was unable to be locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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Licensee retrieved all S1's medication and centrally stored them in a safe location.
Licensee will submit a photo proof of new lock for S1's door.
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: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3