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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700704
Report Date:
02/28/2024
Date Signed:
02/28/2024 05:49:33 PM
Document Has Been Signed on
02/28/2024 05:49 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:
A HEARTY CARE HOME I
FACILITY NUMBER:
342700704
ADMINISTRATOR:
CLARDY, MARIA J
FACILITY TYPE:
740
ADDRESS:
5794 SPENLOW WAY
TELEPHONE:
(916) 339-6440
CITY:
SACRAMENTO
STATE:
CA
ZIP CODE:
95835
CAPACITY:
6
CENSUS:
4
DATE:
02/28/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
02:45 PM
MET WITH:
Administrator- Maria Clardy
TIME COMPLETED:
06:00 PM
NARRATIVE
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On 02/28/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a required 1- year annual inspection. LPA met with caregiver Aurora Hudson and explained the purpose of the visit. LPA requested for staff to notify administrator of LPA's presence at the facility. Administrator, Maria Clardy later arrived at the facility.
LPA and Caregiver conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: five (5) residents room, two(2) bathrooms, kitchen, storage area, and the common areas. LPA observed the facility to have 2+ days of perishable and 7+ days of nonperishable foods.
LPA conducted a file review of two (2) resident files. LPA observed one (1) resident file to be missing the LIC602 and pre-admission appraisal. LPA reviewed two (2) personnel records. LPA observed both files to be incomplete with no first aid training and annual training. LPA observed one (1) personnel file to be missing a health screening report. LPA observed one (1) staff working at the facility who is not fingerprint cleared. Administrator stated they have been working for a week, and staff were not fingerprint cleared. LPA additionally provided facility with LIC311f which states required documents for personnel and resident files.
LPA completed the full care tool, deficiencies was observed and civil penalties was assessed. Please see LIC 809-D.
Exit interview conducted and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME:
Laura Munoz
TELEPHONE:
(916) 263-4743
LICENSING EVALUATOR NAME:
Cheyenne Ratajczak
TELEPHONE:
(916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE:
02/28/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/28/2024
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
5
Document Has Been Signed on
02/28/2024 05:49 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:
A HEARTY CARE HOME I
FACILITY NUMBER:
342700704
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above due to caregiver not being fingerprint cleared which poses an immediate health and safety risk to persons in care.
POC Due Date:
02/29/2024
Plan of Correction
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Licensee removed caregiver from the facility immediatly. Staff cannot come back to facility until fingerprint cleared. Licensee will submit a statement of understanding to LPA Ratajczak that all staff must be fingerprint cleared prior to wokring in the facility.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
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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:
Laura Munoz
TELEPHONE:
(916) 263-4743
LICENSING EVALUATOR NAME:
Cheyenne Ratajczak
TELEPHONE:
(916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE:
02/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/28/2024
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
02/28/2024 05:49 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:
A HEARTY CARE HOME I
FACILITY NUMBER:
342700704
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
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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2
3
4
Based on record review, the licensee did not comply with the section cited above S2 does not have a health screening present in their file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/20/2024
Plan of Correction
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Licensee is to aduit all staff files to ensure everyone has a health screening. Additionally, Licensee will submit to LPA Ratajczak S2 health screening report by POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in staff file does not have annual trainings which poses a potential health, safety risk to persons in care.
POC Due Date:
03/13/2024
Plan of Correction
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Licensee will conduct an annual training with staff by the POC due date and submit to LPA Ratajczak a list of topics covered as well as staff signatures indicating who has completed the training.
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:
Laura Munoz
TELEPHONE:
(916) 263-4743
LICENSING EVALUATOR NAME:
Cheyenne Ratajczak
TELEPHONE:
(916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE:
02/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/28/2024
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
02/28/2024 05:49 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:
A HEARTY CARE HOME I
FACILITY NUMBER:
342700704
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above, two staff do not have first aid training which poses a potential health and safety risk to persons in care.
POC Due Date:
03/13/2024
Plan of Correction
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Licensee is to have both staff complete first aid training by POC due date and submit to LPA Ratajczak a copy of certificate for both staff.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above R1 did not have a pre- admission appraisal completed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/13/2024
Plan of Correction
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Licensee is complete appraisal for R1 by POC due date and submit to LPA Ratajczak a statement of understanding the importance of pre- admission appraisal prior to accepting residents
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:
Laura Munoz
TELEPHONE:
(916) 263-4743
LICENSING EVALUATOR NAME:
Cheyenne Ratajczak
TELEPHONE:
(916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE:
02/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/28/2024
LIC809
(FAS) - (06/04)
Page:
4
of
5
Document Has Been Signed on
02/28/2024 05:49 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:
A HEARTY CARE HOME I
FACILITY NUMBER:
342700704
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/28/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 2 resident files were missing a medical assessment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/20/2024
Plan of Correction
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4
Licensee is to notify LPA Ratajczak once R1's LIC602 is completed.
Licensee is to submit a statement of understanding that all residents in care are to have a completed LIC602 in their records and that LIC602s need to be updated annually.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:
Laura Munoz
TELEPHONE:
(916) 263-4743
LICENSING EVALUATOR NAME:
Cheyenne Ratajczak
TELEPHONE:
(916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE:
02/28/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/28/2024
LIC809
(FAS) - (06/04)
Page:
5
of
5