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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700785
Report Date: 12/04/2024
Date Signed: 12/04/2024 11:13:43 AM

Document Has Been Signed on 12/04/2024 11:13 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:7125 MAIN, LLCFACILITY NUMBER:
342700785
ADMINISTRATOR/
DIRECTOR:		GLADYS GASTAFACILITY TYPE:
740
ADDRESS:7125 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 3DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Staff, Sevrena MillerTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains arrived on 12/04/24 to conduct the annual inspection. LPA met with Staff, Sevrena Miller and explained the purpose of today's visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed two residents (2) and two staff files (2). Staff files have required paperwork. LPA found missing documents in residents (R1,R2) files and citation has been issued as indicated on LIC809D.

LPA and staff toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Hot water temperature was observed to be 118 degrees F, which is within the regulation range of 105-120 degree. Fire extinguisher was serviced on 03/15/24 and was ready for emergency use.

LPA audit medications for residents, R1,R2. During record review, LPA found multiple medications management issues for R2 and citation has been issued as indicated on LIC809D.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 12/31/24 .
Deficiencies are cited on LIC809D per Title 22 Regulations. Exit interview conducted. Appeal Rights and copy of this report left at facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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 3
Document Has Been Signed on 12/04/2024 11:13 AM - It Cannot Be Edited


Created By: Talwinder Bains On 12/04/2024 at 10:48 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: 7125 MAIN, LLC
FACILITY NUMBER: 342700785

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Record review indicated mulpile medications management issues with resident, R2, Including missing prescribed medications ( Escitalopram 20 mg) and Levothyroxine 25mcg, Wrong medication Lidocaine patch 4% (order was for 5%), Acetaminophen 500 mg (order was for 325 mg), Lactobacillus Caps ( not matching Doctor's orders and with expired date). which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2024
Plan of Correction
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Licensee/administrator will send letter of understanding of regulation 87465 and will do staff training and will send proof to department by POC date,12/05/24. Additionaly, Facility shall do monthly staff training for medication administration till Feb.2025 and send training documents to LPA.
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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/04/2024 11:13 AM - It Cannot Be Edited


Created By: Talwinder Bains On 12/04/2024 at 10:48 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: 7125 MAIN, LLC
FACILITY NUMBER: 342700785

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff interview and record review, it was found out that Annual ,LIC602 and Re-appraisal was not completed for 2024 Residents, R1,R2 with Dx-Dementia which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2025
Plan of Correction
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Licensee/administrator shall send a letter of understanding of this Regulation and shall complete all required paperwork for residents, R1, R2 and for all other residents as required and shall notify Department upon completion. All POC documents are due by 01/04/25.
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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
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