342701146-5-8-2023-27-AS-VMOI-CRMRXQ-20230508132507

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701146
Report Date: 05/08/2023
Date Signed: 05/08/2023 01:25:24 PM

Document Has Been Signed on 05/08/2023 01:25 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:	HOMECARE EL SHAMAH		FACILITY NUMBER:	342701146
ADMINISTRATOR:	NAWASA, APAKUKI		FACILITY TYPE:	740
ADDRESS:	4991 44TH STREET		TELEPHONE:	(209) 688-7591
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95820
CAPACITY: 6		CENSUS: 3	DATE:	05/08/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Kuki Nawasa		TIME COMPLETED:	01:30 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	Licensing Program Analyst (LPA) Vincent Moleski and Licensing Program Manager (LPM) Stephen Richardson arrived unannounced to conduct a post-licensing inspection. Moleski and Richardson met with administrator Kuki Nawasa and explained the purpose of the visit. Nawasa's administrator certificate number is 6028899740, and it expires on 06/05/2024. Moleski and Richardson reviewed one resident file (R1) and two staff files (S1, S2). S1's file was missing the required health screening report. S2's file was missing the required health screening report. Moleski, Richardson and Nawasa observed that neither S1 nor S2 were associated to the facility in Guardian, and lacked the required fingerprint clearances. S2 was removed from the facility. S1 was not present at the facility at the time of the visit. Moleski and Richardson toured the facility with Nawasa and inspected common areas, kitchen, bedrooms, bathroom areas and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. Moleski and Richardson observed a first aid kit and working carbon/smoke detectors. Moleski and Richardson observed a minimum 2-day perishable supply and a 7-day supply of nonperishable food. Moleski and Richardson observed two fire extinguishers lacking a tag or receipts. Nawasa told Moleski and Richardson that he purchased the fire extinguishers more than a year prior. Moleski, Richardson and Nawasa observed medications kept unlocked, stored in the facility refrigerator. Moleski, Richardson and Nawasa observed cleaning solutions kept unlocked. [Continued on 809-C]

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

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: HOMECARE EL SHAMAH	FACILITY NUMBER: 342701146
	VISIT DATE: 05/08/2023

NARRATIVE

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Moleski, Richardson and Nawasa reviewed MARs and other medical documents. Moleski, Richardson and Nawasa observed that R1's MARs did not reflect dosages properly and did not include all medications on hand at the facility. Moleski, Richardson and Nawasa observed that there was no centrally stored medication record for R1.

Moleski and Richardson conducted an exit interview with Nawasa. Appeal rights and a copy of this report was left with Nawasa.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/08/2023 01:25 PM - It Cannot Be Edited

Created By: Vincent Moleski On 05/08/2023 at 12:20 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: HOMECARE EL SHAMAH	FACILITY NUMBER: 342701146
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87412(a)(13)(B)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of personnel records and Guardian, the licensee did not comply with the section cited above for two employees (S1 and S2), which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2023
	Plan of Correction
1 2 3 4	Licensee agrees to acquire a BCIA 8016 for each employee and submit it to the Department of Justice.

Type A

Section Cited

CCR

87465(a)(2)

Incidental Medical and Dental Care Services

(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of resident and facility records, the licensee did not create and maintain a centrally stored medications log for R1, did not appropriately update R1's MARs with current medications, and did not appropriately record dosages on the MARs, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2023
	Plan of Correction
1 2 3 4	Licensee agrees to acquire a centrally stored medication and destruction record for all residents, and will train staff members on recording medications administered on the MARs, as well as on transferring prescription information onto new MARs.

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:

Vincent Moleski

LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 05/08/2023 01:25 PM - It Cannot Be Edited

Created By: Vincent Moleski On 05/08/2023 at 12:20 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: HOMECARE EL SHAMAH	FACILITY NUMBER: 342701146
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation of facility grounds the licensee did not properly lock up medications, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2023
	Plan of Correction
1 2 3 4	Licensee agrees to acquire a locked container for medications which must be refrigerated, and will train staff on properly locking up medications.

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:

Stephen Richardson

LICENSING EVALUATOR NAME:

Vincent Moleski

LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC809 (FAS) - (06/04)

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