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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701017
Report Date: 02/06/2023
Date Signed: 02/06/2023 03:49:29 PM

Document Has Been Signed on 02/06/2023 03:49 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SHARMILA CARE SERVICES LLCFACILITY NUMBER:
342701017
ADMINISTRATOR:SINGH, SHARMILAFACILITY TYPE:
735
ADDRESS:2149 MEADOWVIEW ROADTELEPHONE:
(510) 301-4558
CITY:SACRAMENTOSTATE: CAZIP CODE:
95832
CAPACITY: 3CENSUS: 3DATE:
02/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sharmila SinghTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit on 2/6/23 at 2:30pm. LPA met with Sharmila Singh and stated the purpose of the visit. LPA requested to see the Medication Record in which Regional Center deemed a deficiency of medication error on 10/6/22 that was cleared on 10/19/22. LPA observed the Medication Administration Record (MAR) for resident #1 and the training provided to staff for MAR use and medication training.

Administrator confirmed that the errors occurred. The MARs was not completed correctly as she was transferring the medications from one log to the other. The medications for resident #1 were not missed but discontinued by the doctor before the resident moved into the home. However, the medication remained on the medication list.

The Administrator has since then updated the MAR by removing discontinued medications, ensured prescriptions usage frequency are on medications, ensured all medications if possible are in bubble packs, and medications are locked at all times when not in use.

The Administrator conducted in-service training for staff regarding medication management and record keeping on 12/5/22 and 1/6/23.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2023
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 02/06/2023 03:49 PM - It Cannot Be Edited


Created By: Victoria Brown On 02/06/2023 at 03:08 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SHARMILA CARE SERVICES LLC
FACILITY NUMBER: 342701017

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2023
Section Cited
CCR
80070(b)(10)

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Client Records

Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.
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Administrator shall conduct training for staff regarding medication management and record keeping.

Plan of Correction cleared prior to todays visit.
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This requirement is not met as evidenced by: Medication Record not completed
Based on Administrator confirmed the records were incomplete.
This violation poses a potential health, and safety risk to residents in care.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023


LIC809 (FAS) - (06/04)
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