<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700805
Report Date:
05/29/2024
Date Signed:
05/29/2024 04:26:38 PM
Document Has Been Signed on
05/29/2024 04:26 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 FACILITY
FACILITY NUMBER:
342700805
ADMINISTRATOR/
DIRECTOR:
WOODWARD, ROSE BALURO
FACILITY TYPE:
740
ADDRESS:
5016 WATERBURY WAY
TELEPHONE:
(530) 762-8199
CITY:
FAIR OAKS
STATE:
CA
ZIP CODE:
95628
CAPACITY:
6
CENSUS:
6
DATE:
05/29/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:
Rose Baluro Woodward, Administrator
TIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 5/29/24 to conduct a Required-1 Year Inspection utilizing the inspection tool.
LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are four bedrooms and one bathroom for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathroom was in sanitary condition and properly maintained.
LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use. LPA reviewed six (6) resident files and two (2) staff file. Facility has a current copy of certificate of liability insurance and LPA obtained a copy.
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 Administrator. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.
SUPERVISORS NAME
:
Anthony Perez
LICENSING EVALUATOR NAME
:
Michael Hood
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/29/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/29/2024
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
5
Document Has Been Signed on
05/29/2024 04:26 PM
- It Cannot Be Edited
Created By:
Michael Hood
On
05/29/2024
at
03:45 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:
05/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(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:
Deficient Practice Statement
1
2
3
4
Based on LPA's 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 127 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.
POC Due Date:
05/30/2024
Plan of Correction
1
2
3
4
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.
Type A
Section Cited
CCR
87309(a)
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
1
2
3
4
Based on LPA's observations, the facility did not ensure that chemical, tools, and other items that could pose a danger to residents if readily available were locked and inaccessible to residents in the kitchen, bathroom, garage, and backyard area, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/30/2024
Plan of Correction
1
2
3
4
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.
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:
05/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/29/2024
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
05/29/2024 04:26 PM
- It Cannot Be Edited
Created By:
Michael Hood
On
05/29/2024
at
03:45 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:
05/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(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:
Deficient Practice Statement
1
2
3
4
Based on LPA's 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.
POC Due Date:
05/30/2024
Plan of Correction
1
2
3
4
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.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
05/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/29/2024
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
05/29/2024 04:26 PM
- It Cannot Be Edited
Created By:
Michael Hood
On
05/29/2024
at
03:45 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:
05/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observations, the facility did not ensure that the premises was clean, safe and sanitary in the garage, backyard area, living room area, and kitchen refrigerator, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/29/2024
Plan of Correction
1
2
3
4
Licensee will clean facility and clear clutter and debris by POC due date. LPA will return at a future date to ensure that facility is clean, safe, and sanitary.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observations and records reviewed, facility did not ensure that one (1) of six (6) residents had an LIC 602A on file, which poses/posed a potential health, safety or personal rights risk to persons in care. A civil penalty in the amount of $250 was assessed for repeat violation.
POC Due Date:
06/29/2024
Plan of Correction
1
2
3
4
Facility will ensure that all residents obtain a Physician's Report LIC 602A and that documentation is maintained at the facility at all times. Facility will submit missing LIC 602A for one (1) resident to LPA by POC due date.
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:
05/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/29/2024
LIC809
(FAS) - (06/04)
Page:
4
of
5
Document Has Been Signed on
05/29/2024 04:26 PM
- It Cannot Be Edited
Created By:
Michael Hood
On
05/29/2024
at
03:46 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:
05/29/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observations, the facility did not ensure that fire extinguisher was serviced and fire exits were unobstructed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/30/2024
Plan of Correction
1
2
3
4
Facility will ensure that evacuation exits are clear of clutter and debris and are unobstructed. Facility will service fire extinguisher. LPA will return to facility on a future date to clear deficiency.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
05/29/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/29/2024
LIC809
(FAS) - (06/04)
Page:
5
of
5