342700883-9-15-2023-27-AS-PLEE-CVPUWD-20230915155634

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700883
Report Date: 09/15/2023
Date Signed: 09/15/2023 03:56:46 PM

Document Has Been Signed on 09/15/2023 03:56 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	DAWSON'S LODGE		FACILITY NUMBER:	342700883
ADMINISTRATOR:	DAWSON-LACY, VERONICA L.		FACILITY TYPE:	740
ADDRESS:	5650 MARTIN LUTHER KING JR BLV		TELEPHONE:	(916) 421-0233
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95824
CAPACITY:	12	CENSUS: 9	DATE:	09/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Veronica L. Dawson-Lacy		TIME COMPLETED:	04:10 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	On 09/15/2023 at 12:00 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator, Veronica L Dawson-Lucy. LPA Lee explained the purpose of the visit. Administrator assisted with today’s visit. Administrator Certificate # is 6049136740 and will expires on 10/07/2024. The current census is 9 with 2 facility staff. This facility is a single story building licensed to serve twelve (12) ambulatory residents only. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee observed sufficient seven day non-perishable and two day perishable food supplies. LPA Lee observed chemical under the kitchen sink made accessible residents. Hot water temperature was measured at 116.1 degrees Fahrenheit in kitchen sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. LPA Lee observed both resident bath missing a non-slip mat. Fire extinguishers, smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher was last serviced on 08/25/2023. LPA Lee observed the facility has a has a public telephone in the dining area and the facility have the required posters posted. The facility has infection control plan and has an emergency disaster plan. Facility thermostat observed at 72 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed 5 out of 9 residents medication and it was learned that the facility doesn't use Medical Administration Record (MAR) sheets or Centrally Stored Medication Destruction Record (CSMDR). Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

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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Document Has Been Signed on 09/15/2023 03:56 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DAWSON'S LODGE	FACILITY NUMBER: 342700883
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. The licensee did not ensure that staff files were complete. Staff files was missing LIC 501, personnel record, LIC 503, Health and Screening Results with TB, LIC 9052, Employee Rights and Medical Training Verification, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2023
	Plan of Correction
1 2 3 4	Licensee agrees to complete Staff 1 (S1) file by getting the following documents complete: LIC 501 personnel record with education, LIC 503 Health and Screening Results, and TB. Licensee also agrees to complete (S2)'s file by getting the following documents complete: First aid/CPR, LIC 503 Health and Screening Results, TB, LIC 9052 Employee Rights, and Medical Training Verification. Licensee also agrees to read and write a statement of acknowledgment that licensee have read the regulations being cited and have understood the regulation. POC will be emailed to LPA Lee at pang.lee@dss.ca.gov by 10/15/2023 by 5:00 PM by end of day.

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, interview and record review, the licensee did not comply with the section cited above. The licensee did not ensure residents file were complete. Resident 1 (R1) is missing LIC 601 Identification/emergency , Individual Plan (IPP), LIC 613 Personnel Rights, MAR sheet or CSDMR, and TB. (R2) is missing: LIC 625 Needs and Services, CSMDR or MAR sheet, LIC 613 personal right. (R3) is missing MAR or CSMDR and LIC 625 Needs and service plan. (R4) is missing CSMDR or MAR sheet, LIC 625 Needs and Service Plan, LIC 613 Personal Right. (R5) is missing TB, MAR or CSMDR, LIC 625 Needs and Service Plan, LIC 601 Identification/Emergency Sheet, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2023
	Plan of Correction
1 2 3 4	Licensee agrees to complete review all resident files and complete all missing documents listed above. Licensee also agrees to read and write a statement of acknowledgment that licensee have read the regulations being cited and have understood the regulation. POC will be emailed to LPA Lee at pang.lee@dss.ca.gov by 10/15/2023 by 5:00 PM by end of day.

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/15/2023 03:56 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DAWSON'S LODGE	FACILITY NUMBER: 342700883
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(d)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. The licensee did not ensure there was a plan in place for the facility to document medication being distributed to residents. Facility does not use Medication Administration Record (MAR) or Centrally Stored Medication Destruction Record (CSMDR). Administrator stated that they just give residents their medication per doctor direction, but does not have a tracking system, which poses/posed a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 10/15/2023
	Plan of Correction
1 2 3 4	Licensee agrees to use MAR sheets moving forward as a plan in place for the facility to keep track of distributing residents’ medications. Licensee agrees to review regulation cited and write a statement acknowledging that licensee have read and understood regulation being cited. Licensee will email LPA Lee at pang.lee@dss.ca.gov five residents MAR sheets for the month of September 18th to October 15th by end of day 5:00 PM

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DAWSON'S LODGE	FACILITY NUMBER: 342700883
	VISIT DATE: 09/15/2023

NARRATIVE

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LPA Lee advised the administrator that the facility needs to have a plan for distributing medications to each resident when licensing comes out to the facility to check on residents medications. First aid kit was checked and is complete. LPA Lee requested residents and staff files for review. LPA Lee reviewed 5 out of 9 resident files and 2 out of 2 staff files and they were all incomplete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by 09/22/2023 by 5:00 PM by end of day:

(1) LIC 308 Designation of Administrative Responsibility

(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC809 (FAS) - (06/04)

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