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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701120
Report Date: 08/06/2024
Date Signed: 08/06/2024 04:18:20 PM

Document Has Been Signed on 08/06/2024 04:18 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FREDERICKSON HOME IIFACILITY NUMBER:
342701120
ADMINISTRATOR/
DIRECTOR:		FREDERICKSON, VALERIEFACILITY TYPE:
735
ADDRESS:5320 MATINA DR.TELEPHONE:
(916) 686-7358
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 4DATE:
08/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:06 PM
MET WITH:Susan DonatoTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit. LPA Valerio met with facility staff Rose, and explained the purpose of the visit. Facility staff contacted Administrator Valerie via cell phone. LPA Valerio read the report via cell phone. Administrator Valerie designated facility staff Susan to sign on her behalf.

LPA Valerio received a Facility Action Report (FAR) from Alta California Regional Center (ACRC) dated 07/01/2024. The facility was under a corrective action plan with ACRC due to a medication error discovered on 06/17/2024. ACRC found that Resident 1 (R1) was ordered to received calcium 600 mg PO, however, the facility was providing R1 with calcium 500mg PO. FAR dated 07/01/2024 stated that the facility developed a written protocol to ensure clients are receiving the medication as prescribes, conducted an in-service training on the protocol, and submit an incident report for the medication error.

Per California Code of Regulations (CCR) – Title 22, deficiencies are being cited on the attached LIC 809 – D page. An exit interview was held, and a copy of the report was provided to facility staff Susan. Appeal rights were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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 08/06/2024 04:18 PM - It Cannot Be Edited


Created By: Christina Valerio On 08/06/2024 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FREDERICKSON HOME II
FACILITY NUMBER: 342701120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2024
Section Cited
CCR
80075(b)(5)(B)

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80075 Health Related Services(b) Clients shall be assisted(5)...with self-administration, providing all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
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Licensee will sent LPA a copy of the written protocol to ensure clients are receiving the medication as prescribes and copy of the in-service training on the protocol by POC due date.
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Based on records review, the licensee did not ensure to provide R1 medications as prescribed by their physician, which 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:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


LIC809 (FAS) - (06/04)
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