342700843-7-24-2023-27-AS-VMOI-CU2RHQ-20230724130243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700843
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:02:50 PM

Document Has Been Signed on 07/24/2023 01:02 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	PADUA ASSISTED LIVING 2		FACILITY NUMBER:	342700843
ADMINISTRATOR:	DAYOAN, ANGELITA		FACILITY TYPE:	740
ADDRESS:	2929 BABSON DRIVE		TELEPHONE:	(279) 333-7621
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	6	CENSUS: 5	DATE:	07/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Angelita Dayoan		TIME COMPLETED:	01:15 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) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Angelita Dayoan and explained the purpose of the visit. LPA Moleski reviewed three resident files (R1-R3) and three staff files (S1-S3). S2's health screening report did not indicate that a chest x-ray or tuberculosis skin test were performed. LPA Moleski reviewed medication storage and medication administration records (MARs) for R4. LPA Moleski counted 18 signed administrations of a medication which had been filled in a 14-count bottle. Dayoan said a staff member signed the MAR when doses were not, in actuality, given. LPA Moleski toured the facility with Dayoan and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. While inspecting a resident bedroom, LPA Moleski observed a bed bug shell present on a resident's bed. On another bed in the same room, LPA Moleski observed spotting on a pillowcase. LPA Moleski photographed the shell and the spotting. The facility temperature was 75 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 109 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. [continued on 809-C]

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PADUA ASSISTED LIVING 2	FACILITY NUMBER: 342700843
	VISIT DATE: 07/24/2023

NARRATIVE

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LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed two staff members (S1-S2) and two residents (R3-R4).

This facility is being cited per 22 CCR Sections 87411(f), 87465(a)(4) and 87303(a). An exit interview was held with Dayoan. Appeal rights and a copy of this report were left with Dayoan.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/24/2023 01:02 PM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PADUA ASSISTED LIVING 2	FACILITY NUMBER: 342700843
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of S2's personnel file, the licensee did not ensure S2 had proof of either a tuberculosis skin test or a chest x-ray, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2023
	Plan of Correction
1 2 3 4	Licensee agrees to have S2 conduct another health screening, including either a tuberculosis skin test or a chest x-ray. Licensee agrees to send new health screening to LPA Moleski. vincent.moleski@dss.ca.gov

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 07/24/2023 01:02 PM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PADUA ASSISTED LIVING 2	FACILITY NUMBER: 342700843
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2023

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 observation of a bed bug shell and spotting on beds in a resident bedroom, the licensee did not ensure the facility was clean and/or sanitary, such that bed bugs proliferated in a resident bedroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2023
	Plan of Correction
1 2 3 4	Licensee agrees to procure extermination services for bed bugs. Licensee agrees to send LPA Moleski proof of having aquired or scheduled these services by the POC due date. vincent.moleski@dss.ca.gov

Type B

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of R4's medications, MARs, and centrally stored medication list, the licensee did not ensure accurate records of medication administrations were maintained, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/30/2023
	Plan of Correction
1 2 3 4	Licensee agrees to conduct a staff training regarding medication administration. Licensee agrees to send a sign-in sheet from this training to LPA Moleski. vincent.moleski@dss.ca.gov

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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