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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700896
Report Date: 04/25/2024
Date Signed: 04/25/2024 11:53:29 AM

Document Has Been Signed on 04/25/2024 11:53 AM - 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:MVP CAREHOMEFACILITY NUMBER:
342700896
ADMINISTRATOR/
DIRECTOR:		PURUGGANAN, EVELETH R.FACILITY TYPE:
735
ADDRESS:5914 WEDGEWOOD AVENUETELEPHONE:
(909) 384-2276
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Paz YntelaTIME VISIT/
INSPECTION COMPLETED:
11:47 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived announced at the facility to conduct a required annual inspection, utilizing the full CARE tool. LPA met with caregiver, Paz Yntela, and explained the purpose of the visit. Caregiver contacted Administrator, Eveleth Purugganan, who arrived to the facility after facility tour was conducted.

During time of visit, there was no clients present as 5 out of 5 clients were at adult day program.

LPA and Caregiver conducted a tour of the interior and exterior of the facility to ensure the health and safety of clients in care. In areas toured included but not limited to: two bathrooms, three private clients room, one shared client room, kitchen, laundry room, backyard and the common areas. LPA observed facility to be at 68*. LPA was informed if clients in care would like the temperature to be adjusted, facility does accommodate to change thermostat. During facility tour, LPA observed two laundry detergents present on a shelf on top of the washer machine. LPA informed Caregiver that cleaning solutions are to kept locked with all the other chemicals. LPA provided Administrator a copy of California Code of Regulation, Title 22 80087 Buildings and Grounds.

File review was conducted for 5 clients, and 5 personnel files.

At this time, Administrator stated there are no concerns at the facility. LPA requested a copy of LIC308, LIC500 and Administrator Certificate to be submitted to LPA by Friday May 3, 2024. Care tool completed and deficiencies cited.

Exit interview and a copy of the report and appeal rights provided to Administrator.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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 04/25/2024 01:54 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/25/2024 01:51 PM


Created By: Cassie Yang On 04/25/2024 at 11:31 AM
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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MVP CAREHOME
FACILITY NUMBER: 342700896

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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
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Based on observation, the licensee did not comply with the section cited above as LPA observed two laundry solutions to be stored on top of washer while clients were out of the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee is to conduct an in-service training with DSPs/Caregivers on how to store disinfectants, cleaning solutions, poisons, firearms and other dangerous items away immediately after use. Attendence sheet is to be provided to LPA via fax or email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


LIC809 (FAS) - (06/04)
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