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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700950
Report Date: 03/30/2023
Date Signed: 04/03/2023 11:39:31 AM


Document Has Been Signed on 04/03/2023 11:39 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:DELL ROAD HOMEFACILITY NUMBER:
342700950
ADMINISTRATOR:MAGEE, ANDREWFACILITY TYPE:
740
ADDRESS:3840 DELL ROADTELEPHONE:
(916) 333-3103
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Persida PopTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility announced on 3/28/23 to conduct a Annual Inspection. LPA met with staff designee and explained the purpose of the visit. LPA PPE was worn: surgical Mask.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA noted deficiencies in facility, staff and resident records. Water temperature needs to be adjusted .Licensee fees are late.


As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Persida . Copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
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 4


Document Has Been Signed on 04/03/2023 11:39 AM - 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: DELL ROAD HOME
FACILITY NUMBER: 342700950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023

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
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4
Based on observations and statements, the licensee did not comply with the section cited above in not haveing staff files available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2023
Plan of Correction
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4
Staff required records will be submitted for S1 and S2 by the POC date of 4/13/23
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on S! and S2 were able to provide proof of finger print clearance however licensee has not associated them to this facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2023
Plan of Correction
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4
Licensee will provide proof of association by 4/2/23
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 04/03/2023 11:39 AM - 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: DELL ROAD HOME
FACILITY NUMBER: 342700950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(b)
Other Provisions
(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and statements the licensee did not comply with the section cited above in 2 of 2 staff did not have proof or required training present during the inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2023
Plan of Correction
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2
3
4
Licensee will provide proof of required training for R1 and R2 by the POC date of 4/20/23
Type B
Section Cited
CCR
87705(c)(3)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 2 of 2 staff did not have training presentwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2023
Plan of Correction
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4
Licensee will provide proof of training by the POC date of 4/13/23.
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/03/2023 11:39 AM - 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: DELL ROAD HOME
FACILITY NUMBER: 342700950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and statement the licensee did not comply with the section cited above in the kitcheswhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2023
Plan of Correction
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Licensee will provide proof of lock repair/ replacement by the POC date of 4/13/23
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4