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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701130
Report Date: 02/02/2024
Date Signed: 02/02/2024 03:23:08 PM


Document Has Been Signed on 02/02/2024 03:23 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:COMFORTS OF HOME GAVIRATEFACILITY NUMBER:
342701130
ADMINISTRATOR:PARAS, FAITHFACILITY TYPE:
740
ADDRESS:9823 GAVIRATE WAYTELEPHONE:
(916) 897-9465
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 5DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Faith ParasTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA met with facility staff Violeta, and explained the purpose of today's visit. LPA was later met by Administrator Faith Paras.

LPA Valerio and Facility Staff Violeta toured the facility to ensure compliance with Title 22 regulations. LPA measured the hot water temperatures in both bathrooms that are utilized by residents. Water temperature reads 118.2° F in the bathroom by the kitchen and 119.5 in the bathroom, within regulatory range of 105 *F and 120 *F. Room temperature reads 73° F. LPA observed the facility to have adequate food supply. The facility refrigerator is broken; however, they have a new one arriving next week. The facility has a separate freezer and smaller refrigerator to store items until the new refrigerator arrives. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers was up to date with last check on 01/27/2024. Medications cabinet was locked. The facility was observed to have a first aid kit. Chemical, toxins, and cleaning supplies were locked and inaccessible to residents in care. All emergency exits were from obstructions. LPA inspected the shed located in the exterior area, which was observed to used for storage. LPA reviewed 3 staff and 2 resident files. Technical Assistance was provided for 1 out of 3 staff files reviewed. Resident files were observed to be incomplete with missing appraisals and needs and service plans. Last emergency drill was conducted on 09/22/23.

LPA requested the following annual documentation be sent to the Regional Office: LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Report, Copy of Administrator Certificate, LIC 610 Emergency Disaster Plan, and Proof of Current Liability Insurance.

Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, deficiencies were observed during today's visit. Appeal Rights Provided. Failure to correct deficiencies may result in civil penalties. An exit interview was held, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 02/02/2024 03:23 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: COMFORTS OF HOME GAVIRATE
FACILITY NUMBER: 342701130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review of 2 residents files, the licensee did not comply with the section cited above in 1 out 2 files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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Licensee to review 87506(b)(15), review regulations with all staff, submit a statement of acknowledgement to LPA Valerio by POC due date. Licensee to go through all resident files to ensure all files are within compliance by POC due date.
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) 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, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 2 out of 2 resident files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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Licensee will ensure all resident files have up to date appraisals and Needs and Service Plans. Licensee to send LPA Valerio notification of completion by POC due date.
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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3