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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700805
Report Date: 08/27/2024
Date Signed: 08/27/2024 03:18:11 PM

Document Has Been Signed on 08/27/2024 03:18 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:NORTHERNCARE FACILITYFACILITY NUMBER:
342700805
ADMINISTRATOR/
DIRECTOR:		WOODWARD, ROSE BALUROFACILITY TYPE:
740
ADDRESS:5016 WATERBURY WAYTELEPHONE:
(530) 762-8199
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 5DATE:
08/27/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Rose Baluro Woodward, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility and met with Licensee, Rose Baluro Woodward, to follow-up on plan of corrections made to the facility during an inspection conducted on 5/29/2024.

During today's visit, LPAs conducted a tour of the care home. LPAs observed that fire exits were not obstructed and facility obtain an LIC 602A Physician Report for resident in need.

LPAs observed storage used for centrally stored medication to be unlocked and accessible to residents in care. LPAs observed multiple hazardous items unlocked and accessible to residents in care. LPAs took the temperature of the tap water, which was observed to be 123 degrees F.

As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Civil penalties were assessed as a result of today's visit. Deficiencies are listed on 809-D pages.

Exit interview was conducted with Licensee. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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 08/27/2024 03:18 PM - It Cannot Be Edited


Created By: Michael Hood On 08/27/2024 at 02:27 PM
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: NORTHERNCARE FACILITY
FACILITY NUMBER: 342700805

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/28/2024
Section Cited
CCR
87303(e)(2)

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(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
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Facility will adjust water temperature at the facility to be no less than 105 degrees F and no more than 120 degrees F. LPA will return to facility to check water temperatures. Facility will adjust water temperature by POC due date.
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Based on LPAs' observations, the facility did not ensure that water temperatures were controlled and maintained at not less than 105 degrees F and not more than 120 degrees F when hot water was measured at 123 degrees F, which poses an immediate health, safety or personal rights risk to persons in care. A civil penalty in the amount of $250 was assessed for repeat violation.
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Type A
08/28/2024
Section Cited
CCR87309(a)

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(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:
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Facility will ensure storage for hazardous items and ensure that hazardous items are locked and inaccessible to residents in care by POC due date. LPA will return to facility at a future date to check that all hazardous items are locked and inaccessible to residents in care.
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Based on LPAs' observations, the facility did not ensure that tools and other items that could pose a danger to residents if readily available were locked and inaccessible to residents in the garage and backyard area, which poses an immediate health, safety or personal rights risk to persons 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:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2024 03:18 PM - It Cannot Be Edited


Created By: Michael Hood On 08/27/2024 at 02:57 PM
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: NORTHERNCARE FACILITY
FACILITY NUMBER: 342700805

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/28/2024
Section Cited
CCR
87465(h)(2)

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(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
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Facility will repair existing medication storage or obtain a different medication storage. Facility will ensure that medication storage is locked. LPA will return at a future date to ensure that medications are locked and inaccessible to the residents in care.
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Based on LPAs' observations, the facility did not ensure that medications were locked and inaccessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons 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:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
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