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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700783
Report Date: 09/05/2024
Date Signed: 09/05/2024 10:09:25 AM


Document Has Been Signed on 09/05/2024 10:09 AM - 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:7117 MAIN, LLCFACILITY NUMBER:
342700783
ADMINISTRATOR:GLADYS GASTAFACILITY TYPE:
740
ADDRESS:7117 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 4DATE:
09/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Staff, Sevrena MillerTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 09/05/24 to do case management visit and met with Staff, Sevrena Miller and explained the purpose of the visit.

Based on Incident Report (LIC624) dated 08/29/24 sent by facility to Department, it was indicated that Resident, R1, was found missing by staff around 6:45PM during routine checks. It was learnt that R1 had returned from hospital the same day around 1:30PM, where R1 was treated for mental disorder. Per staff, R1 was doing fine after returning from hospital and took their medications and meals till R1 was found missing around 6:45PM. Staff searched R1 on facility’s property and surrounding areas but could not find R1. Administrator was notified and staff called 9-1-1 and sheriff around 7pm. Per facility records, missing person report was filed under case number, 24-78100. It was also learnt that R1 use to leave facility in the past and R1s LIC602 signed by thier physician indicated that R1 can leave Unassisted, but Authorities made the Alarm for missing person due to R1s mental health issues.

During today’s visit, LPA was informed by staff that R1 was found uninjured on 08/30/24 by law enforcement and currently was at mental health care facility and getting the medical treatment with unknown discharge plan. Facility was in touch with R1s responsible party, social worker and other required parties per regulations regarding R1s health updates.

During record review and staff’s interviews, LPA found that R1 was hospitalized one week prior to this incident where R1 received the treatment for their mental disorder and was in hospital for seven days and returned on 08/29/24. This incident should have been reported to Department per requirement, but facility did not report this incident. Based on this information, per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached LIC809-D page.

Exit interview was conducted, copy of this report and appeal rights were provided. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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 09/05/2024 10:09 AM - 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: 7117 MAIN, LLC
FACILITY NUMBER: 342700783

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2024
Section Cited
CCR
80061(b)

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80061-(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report .... (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event…. This requirement is not met as evidenced by;
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Administrator shall send a letter of understanding of this regulation and shall conduct all staff training and will send proof to department within 15 days. Additionally, Administrator shall ensure to send all incidents to department in timely manner and shall keep records for sending those reports. All POC documents are due by 09/19/24.
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Based on documents reviewed, the facility did not meet reporting requirements for incidents that occurred around 08/22/24 for resident, R1 which poses potential health and safety risks to residents in care.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
LIC809 (FAS) - (06/04)
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