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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700801
Report Date: 01/19/2024
Date Signed: 01/19/2024 12:41:01 PM


Document Has Been Signed on 01/19/2024 12:41 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:MINNESOTA HOME CAREFACILITY NUMBER:
342700801
ADMINISTRATOR:OKYERE, VERA A.FACILITY TYPE:
740
ADDRESS:7448 MINNESOTA DR.TELEPHONE:
(916) 729-9461
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 4DATE:
01/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Annastaycia Kelly, caregiver TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following receipt of an incident report that was submitted to the Department on 1/11/24. LPA met with caregiver, Annastaycia Kelly, who informed LPA the Administrator, Vera Okyere, was not present at the facility currently.

LPA stated reason for the inspection was to follow up on resident (R1) being sent to the emergency room on 1/6/24. The incident report states that (R1) was unable to sit up by himself, trembling and not taking food and medications so was sent to the emergency room.

LPA was instructed by the caregiver to contact the Administrator's spouse by phone. LPA spoke to Steven Doe who explained that the Administrator currently had an emergency and is not able to talk to LPA right now. Steven provided an update on (R1) stating he remains hospitalized due to being confused and non-responsive and is currently in the Intensive Care Unit (ICU). Steven stated he and the Administrator have been trying to contact (R1's) next of kin and have not been able to so far.Steven stated (R1) became weaker and weaker, prior to being admitted to the hospital on 1/6/24, confirming resident did not test positive for Covid. LPA stated she would leave a copy of today's report with the caregiver and asked that the Administrator contact LPA as soon as possible with an update on (R1's) situation.

LPA discussed (R1's) condition with caregiver, Annaastaycia, as she was present on 1/6/24 and the days leading up to (R1) being sent out to the emergency room. LPA reviewed (R1's) file and obtained a copy of when (R1) was seen in the emergency room on 12/26/23. Paperwork was not seen for other recent days when (R1) was seen in the emergency room.

LPA toured the facility and observed (4) residents present- (1) in the common area finishing lunch and (3) in their resident rooms. LPA observed to be clean, safe and not pose any personal rights violations.

There are no deficiencies issued in this report.

Exit interview. Copy of report provided to caregiver.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
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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