342700775-8-20-2020-27-AS-KLEL-BSNR5K-20200820124317

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700775
Report Date: 08/20/2020
Date Signed: 08/20/2020 12:44:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	FOLSOM CARE		FACILITY NUMBER:	342700775
ADMINISTRATOR:	ABELARDO, BERYL		FACILITY TYPE:	740
ADDRESS:	148 STONEY HILL DRIVE		TELEPHONE:	(916) 983-9988
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	5	CENSUS: 4	DATE:	08/20/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:07 AM
MET WITH:	Beryl Abelardo		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Konnor Leitzell conducted a scheduled pre-licensing inspection with Beryl Abelardo (Administrator) via tele-visit on 8/20/2020. Due to COVID-19 and precautionary measures, this inspection was done over Facetime. This is a change in ownership and 4 residents were seen at the facility at this time. LPAs and Administrator toured the interior and exterior of the facility, viewing the common areas, residents bedrooms, bathroom, kitchen, staff room, and laundry. LPA observed the facility to be clean, in good repair and to have sufficient furniture in common areas, both interior and exterior. LPA observed sufficient lighting throughout the facility, and had night time wall lights mounted to hallway wall from residents rooms to the central bathrooms. LPAs viewed the front yard and back yard to have no steps or stairs, plenty of room for activities and shaded patio furniture. LPA viewed a shed in the backyard that was locked and will be used for storage and will remain locked. LPA viewed the thermometer for the running water at 106 degrees in the bathroom, and the refrigerator reading 41 degrees and the freezer reading 1 degrees. After discussing the requirements, both temperatures were lowered to reflect freezer at 0 and refrigerator at 40. Sink faucet only reached 106 degrees. Facility had a 7+ day supply of non-perishables that was located away from toxins and detergents. LPA witnessed an alarm sounding for when exterior doors are opened and closed, as well as a functioning smoke detector and Carbine Monoxide detectors. When viewing the living room, many activities were seen available. LPA viewed the fire extinguisher was last serviced in October 2019. When touring the kitchen, administrator showed LPAs the sharps are locked in cabinet, as well as toxins locked by magnet under the sink. LPAs checked and ensured the facility had sufficient dishes, flatware, cooking pans, and linens. LPA viewed individual "caddies" for residents hygiene products with names visible. Administrator stated linens get washed separately for each resident. LPAs viewed a complete first aid kit. LPAs viewed a locked medications closet. LPA viewed staff bedroom to have two beds, and have no toxins or personnel documents..

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: FOLSOM CARE	FACILITY NUMBER: 342700775
	VISIT DATE: 08/20/2020

NARRATIVE

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LPA observed the following posted at the facility: Resident Personal Rights, Rights of Resident/Family Councils, See Something Say Something, the Facility Sketch with evacuation routes, Ombudsman poster and the non-discrimination clause. LPA viewed bathrooms to have non-slip mats in showers, as well as grab bars around toilet and in shower.

LPA reviewed residents and staff binders and all appropriate documents were seen.

Comp III was conducted during today's inspection. ** Also, COVID-19 staff and resident precautionary measures were also discussed and resources materials were emailed following today's tele-visit. **

LPA Leitzell is to notify the analyst in the application unit of inspection being completed.

An exit interview was conducted with Beryl Abelardo, Administrator during today's tele-visit, and a copy of this report will be provided to the facility via email (sent 8/20/2020 at approximately 12:45 PM.) Two copies will be sent to the facility, 1 is to be signed and returned same day to CCL, and the other copy is to remain at the facility.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2020

LIC809 (FAS) - (06/04)

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