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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701028
Report Date: 05/11/2022
Date Signed: 05/11/2022 04:40:46 PM

Document Has Been Signed on 05/11/2022 04:40 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: 10DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Tatleen LewisTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) K.. Hiratsuka and L. Muscan, arrived at the facility unannounced on 05/11/2022 to conduct an unannounced annual visit using the infection control tool visit. LPA met with Facility Caregiver Tatleen Lewis and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Facility Representative and completed a facility risk assessment. LPA ensured they used hand sanitizer shortly after entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by Caregiver.

LPA and Caregiver toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms.. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Caregiver completed the infection control domain and facility was found to be in substantial compliance for the infection control.

While touring the facility, the following was observed:
-medication cabinets were found not locked. The medications were found with a lever on the bottom of the cabinet that when pushed up the medications are accessible. Title 22 regulations require medications to be locked. This is an immediate risk to residents.
-storage room that stores all the cleaning chemicals located in the second hallway and is across from the laundry room was found unlocked during visit. Per Title 22 regulations all chemicals shall remain locked when not in use by a staff person.

The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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 05/11/2022 04:40 PM - It Cannot Be Edited


Created By: Lavinia Muscan On 05/11/2022 at 04:22 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: 05/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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 in the storage closet that stores the cleaning chemicals was found unlocked during visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Licensee shall submit in writing how he shall ensure the closet is locked when there are no staff present in the closet.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 in the cabinet that stores the medication has a lever when pressed opens the door. This is not a lock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Licensee shall submit in writing how he shall ensure medications are locked when not being tended to by staff.
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:Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022


LIC809 (FAS) - (06/04)
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