342701116-3-15-2023-27-AS-PLEE-CPXUNA-20230315154338

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701116
Report Date: 03/15/2023
Date Signed: 03/15/2023 03:43:55 PM

Document Has Been Signed on 03/15/2023 03:43 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	LAKEWOOD VILLA		FACILITY NUMBER:	342701116
ADMINISTRATOR:	QUIAMBAO, GLADYS		FACILITY TYPE:	740
ADDRESS:	8708 GERBER ROAD		TELEPHONE:	(925) 954-5329
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	18	CENSUS: 15	DATE:	03/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Gladys Quiambao		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03/15/2023 at 8:25 AM Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator Gladys Quiambao and explained the purpose of the visit. Gladys assisted with today’s visit. Administrator certificate # is 6059942740 and will expire on 06/23/2023. The facility has one main Covid-19 screening entry point. The facility has Covid-19 posting throughout the facility. The furniture is spaced six feet apart, and the facility does daily cleaning. The facility has a 30-day supply of PPE. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee inspected four (4) resident bathrooms and observed three (3) our of four (4) resident bathroom had non skid mat. Resident three (3) bathroom was missing a non skid mat. This facility is a single story building licensed to serve eighteen (18) ambulatory residents, of which nine (9) may be non-ambulatory and six (6) may be bedridden. This facility is also approved for hospice waiver for three (3) residents. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 126.1 degrees Fahrenheit in resident bathroom sink. Fire extinguishers, smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 10/13/2022. Facility thermostat observed at 72 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to clients. LPA Lee requested and reviewed Medication Administrator Records and Centrally Stored Log for 7 out of 15 residents in care. Records review revealed that medication administration record for (2) out of (7) resident are missing March initial for every Sunday and Thursday. Policies and procedures related to storing, handling, and documentation of the facility resident medications were discussed with the facility designated Administrator at this time. Continued

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LAKEWOOD VILLA	FACILITY NUMBER: 342701116
	VISIT DATE: 03/15/2023

NARRATIVE

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First aid kit was checked and is complete. LPA Lee requested client and staff files for review. LPA Lee reviewed (7) residents files and (4) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA Lee verified staff training for staff file reviews.

The following documents was submitted to LPA Lee during today's visit
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. Technical assistance (TA) was given for water temperature and non skid mat. An exit interview was conducted, and a copy of this LIC 809 report, LIC 809-D Page, TA and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/15/2023 03:43 PM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LAKEWOOD VILLA	FACILITY NUMBER: 342701116
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, interviews and record review the licensee did not comply with the section cited above in 2 out of 7 residents files which did not have an an updated and completed Medication Administration Record which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/20/2023
	Plan of Correction
1 2 3 4	Facility administrator stated that all resident files with accompanying Medication Administration Record (MAR), should and will be updated and completed at all times. A statement of correction, along with copies of the updated Medication Administration Record (MAR), will be completed and submitted to LPA Lee by POC due date 03/20/2023 for review.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023

LIC809 (FAS) - (06/04)

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