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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700638
Report Date: 09/20/2023
Date Signed: 09/20/2023 04:07:44 PM


Document Has Been Signed on 09/20/2023 04:07 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: 4DATE:
09/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:EGUAVOEN, CHARLESTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a Required 1- year annual inspection utilizing the full CARE tool. LPA met with Caregiver, Abigail Ndukwe, who informed LPA Administrator is not at the facility. LPA entered the facility and contacted Administrator. Administrator arrived to the facility approximately 25 minutes later.

LPA and Administrator discussed the importance of Inspection Authority of Licensing Agency and criminal clearance transfer request.

LPA and Administrator conducted a tour of the interior and exterior of the facility. LPA observed the presence of four residents in care, LPA was informed there is no resident in care under hospice services. LPA and Administrator toured four private residents room, one shared resident room, caregiver room, two bathroom, kitchen, office, storage room, backyard and common areas.

LPA observed the facility to have 2+ days of perishable and 7+ days of non-perishable food. LPA observed toxins, sharps and medication to be locked and secured in the kitchen. LPA observed the fire extinguisher to last service on 01/11/2023. LPA observed temperature of the facility to be 77*. LPA conducted a file review of 3 out of 4 residents file. LPA was unable to inspect 1 out of 2 personnel files. LPA and Administrator discussed that all over the counter medications are to be approved and ordered by physician.

LPA requested a copy LIC500, LIC308 and liability insurance to be emailed to LPA by Friday September 22, 2023 at 5PM.

As a result of today's inspection, deficiencies observed. See LIC 809-D.

Exit interview. 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: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
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 09/20/2023 04:07 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: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
87412 Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and file review, the licensee did not comply with the section cited above as LPA osberved 1 out of 2 personnel file to be unavailable, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Licensee is to ensure all caregivers have a personnel file completed with the required documents.
Licensee is to submit a statement of compliance to California Code Regulation 87412 to LPA by Friday September 22, 2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
LIC809 (FAS) - (06/04)
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