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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700716
Report Date: 06/28/2023
Date Signed: 06/28/2023 03:07:00 PM

Document Has Been Signed on 06/28/2023 03:07 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MIRANDA GARDENSFACILITY NUMBER:
342700716
ADMINISTRATOR:MIRANDA, IANFACILITY TYPE:
735
ADDRESS:2405 RENWICK AVETELEPHONE:
(916) 955-1905
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
06/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Pamela MirandaTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit regarding a facility action report received from Alta California Regional Center (ACRC). LPA Moleski met with administrator Pamela Miranda and explained the purpose of the visit.

ACRC's report states that on 4/4/23, ACRC staff observed one pill stuck in a bubble pack for the evening of 4/2/23. Three of the four pills of this medication were administered to the resident (R1), according to ACRC's report.

LPA Moleski reviewed a facility incident report dated 4/4/23 regarding this incident. The incident report states that three out of four medications were administered to the resident. According to the incident report, the pill was destroyed. The incident report states that the medication is used for sleep and that no other side effects were expected. LPA Moleski reviewed MARs for R1 for the month of April. On 4/2/23, a staff member signed off on the MARs for evening administration of this medication.

This facility is being cited per 22 CCR Section 80075(b). An exit interview was conducted with Miranda. Appeal rights and a copy of this report were left with Miranda.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2023
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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Document Has Been Signed on 06/28/2023 03:07 PM - It Cannot Be Edited


Created By: Vincent Moleski On 06/28/2023 at 02:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MIRANDA GARDENS
FACILITY NUMBER: 342700716

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2023
Section Cited
CCR
80075(b)

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Health Related Services: "(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications."
This requirement was not met as evidenced by:
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 Licensee previously completed staff training regarding medication administration. LPA Moleski reviewed training records during this visit. This POC will be cleared.
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Based on review of ACRC's facility action report, and based on review of the facility's incident report, R1 did not receive the proper dosage of medication on 4/2/23, which poses a potential health and safety risk.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023


LIC809 (FAS) - (06/04)
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