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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700777
Report Date: 06/13/2024
Date Signed: 06/13/2024 03:19:13 PM


Document Has Been Signed on 06/13/2024 03:19 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:SIGNATURE LIVING ON WINDING WAY IIFACILITY NUMBER:
342700777
ADMINISTRATOR:AFABLE, SCOTTFACILITY TYPE:
740
ADDRESS:6270 WINDING WAYTELEPHONE:
(916) 812-0944
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Nomar Sanchez and Scott AfableTIME COMPLETED:
03:55 PM
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On 6/13/2024, Licensing Program Analyst (LPA) Cassie Yang and Department of Consumer Affairs Associate Governmental Program Analyst (AGPA) Jordan McLaughlin arrived unannounced at the facility to conduct a required annual inspection utilizing the care tool. LPA met with caregiver and explained the purpose of the visit. Administrator arrived to the facility after tour was completed.

Today's census is six residents in care with two residents on hospice services. Facility is licensed for six non-ambulatory with hospice waiver of six.

During today's visit, LPA, AGPA and Caregiver conducted a tour of the interior and exterior of the facility. LPA informed Caregiver that master key to medication cabinet should be inaccessible to residents in care. LPA and AGPA observed bleach, laundry detergent and Pinesol located by the laundry area. Toxins were immediately stored after observation. Additionally, LPA and AGPA observed toilet cleaner solution located in the bathroom located near the common areas.

File review conducted for four personnel and six residents. LPA and Administrator discussed that residents with dementia are to be medically assessed annually and residents with no dementia diagnosis medical assessment shall be updated when required by the Department. LPA observed facility files to be completed with the required documents.

LPA observed the presence active facility liability insurance. LPA observed Administrator Certificate #6032256740 to be pending renewal.

Deficiencies cited. Please see LIC 809-D.

Exit interview and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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 06/13/2024 03:19 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: SIGNATURE LIVING ON WINDING WAY II
FACILITY NUMBER: 342700777

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 LPA and AGPA observed four cleaning solutions left accessible which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 06/14/2024
Plan of Correction
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Caregiver gathered the cleaning solutions and stored immediately.
Licensee is to conduct an in-service training with staff on how to store cleaning solutions immediately after use and/or when Caregiver is out of sight of the cleaning solutions.
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: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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