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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701211
Report Date: 01/16/2024
Date Signed: 01/16/2024 05:26:19 PM


Document Has Been Signed on 01/16/2024 05:26 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:STEWART OAKS VILLAFACILITY NUMBER:
342701211
ADMINISTRATOR:FERREIRA, MELANIEFACILITY TYPE:
740
ADDRESS:1099 STEWART ROADTELEPHONE:
(916) 222-1010
CITY:SACRAMENTOSTATE: CAZIP CODE:
95864
CAPACITY:6CENSUS: 6DATE:
01/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Melanie FerreiraTIME COMPLETED:
01:30 PM
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On 01/16/2024 at 12:30 PM Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator Melanie Ferreira and explained the purpose of the visit. Administrator and House Manager Jennifer Campos assisted with today’s visit. Administrator certificate # is 6028106740 and will expire on 12/26/2024. The current census is 6 with 3 facility staff.

This facility is a single story building licensed to serve five (5) non-ambulatory residents, one (1) ambulatory resident in room #3 only and a hospice waiver for two residents. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed (R1) in resident bedroom #3 which is licensed for a ambulatory resident only and (R1) is non ambulatory; therefore, the facility is not adhering to the fire clearance. LPA Lee also observed room #3 had a sliding door and a ramp. It was learned that when the facility got licensed resident bedroom #3 had a sliding door with a deck; however, the deck did not have a ramp. Licensee stated he put in a new ramp in May of 2023. 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 bodies of water present, and it was locked and made inaccessible to residents in care.

LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 137.1 degrees Fahrenheit in the common area resident bathroom sink and 121.1 degrees Fahrenheit in resident bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 11/07/2023.
Continued LIC 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
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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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: STEWART OAKS VILLA
FACILITY NUMBER: 342701211
VISIT DATE: 01/16/2024
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 LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed and compared 3 out of 6 medication administration record (MAR) and it was complete. The first aid kit was checked and contained all the required components. LPA Lee requested resident and staff files for review. LPA Lee reviewed 5 out of 6 resident files and 5 out of 6 staff files and they were all complete. LPA Lee reviewed staff criminal record clearances and 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.

The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by XXXX by 5:00 PM by end of day:

(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 deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2024 05:26 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: STEWART OAKS VILLA
FACILITY NUMBER: 342701211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. The licensee did not ensure that the hot water temperature stay within regulation. Resident bathroom #1 was measured at 137.1 and resident bathroom #2 was measured at 121.1 degrees F; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Administrator will ensure that the hot water is adjusted immediately and remeasured. Administrator will send LPA Lee a video of the hot water being measured and within regulation by 01/18/2024 by end of day. Administrator will also measured the hot water and keep a log and email LPA Lee the log by 01/31/2024 by 5:00 PM end of day.
Type A
Section Cited
CCR
87204(a)
87204 Limitations - Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, interviews and record review, the licensee did not comply with the section cited above. The licensee did not ensure that resident bedroom #3 is only for ambulatory resident. LPA Lee observed resident 1 residing in bedroom #3 who is non-ambulatory.
POC Due Date: 01/17/2024
Plan of Correction
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Licensee will provide LPA Lee permits for the door and ramp for room #3. Licensee will also provide LPA Lee a new facility sketch; which will reflect resident room #3 with sliding door and ramp, LIC 200 and complete 850. Licensee will emailed LPA Lee POC date 01/16/2024 by end of day 5:00 PM.
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-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
LIC809 (FAS) - (06/04)
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