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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701028
Report Date: 04/13/2022
Date Signed: 04/13/2022 03:42:11 PM

Document Has Been Signed on 04/13/2022 03:42 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MKS QUALITY CARE LLCFACILITY NUMBER:
342701028
ADMINISTRATOR:LEE, KEVINFACILITY TYPE:
740
ADDRESS:317 NATOMA ST.TELEPHONE:
(916) 831-7972
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY: 15CENSUS: 8DATE:
04/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Tatleen LewisTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Kerry Hiratsuka and Lavinia Muscan arrived at the facility unannounced and prior to visit LPAs conducted COVID-19 Precautionary pre screening, and wore a surgical mask while at facility. LPAs were screened at the front door by Caregiver.

While investigating complaint, 25-AS-20211118152214, several issues were found that were not allegations, but found to be violations of the regulations. The complaint regarded a resident who fell while at this facility. The resident fell in between staff checks. The resident was here after suffering falls at the previous living location and had back surgery prior to moving in. The resident had a history of falls and was a fall risk. There was no written plan of care addressing the resident's fall risk. The resident's room had a bed alarm, a mat to alert people the resident stood up, and did check on resident, but nothing in writing. Each facility is required to have a written plan of care for each resident to address their needs and how the facility is going to meet their needs.

The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. Appeal rights left with facility representative.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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 04/13/2022 03:42 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 04/13/2022 at 02:34 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: MKS QUALITY CARE LLC
FACILITY NUMBER: 342701028

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2022
Section Cited
CCR
87467(a)

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Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare
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By 04/13/2022, the licensee shall submit a written plan of correction on how he shall ensure the written plan of care for the residents adequately addresses all their health issues and how the facility is going to meet their needs.
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a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. This requirement was not met as evidenced by: there was no written plan of care to address a resident who was a fall risk. This posses an immediate risk to residents.
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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:Troy Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


LIC809 (FAS) - (06/04)
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