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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701211
Report Date: 07/19/2023
Date Signed: 07/19/2023 05:10:52 PM

Document Has Been Signed on 07/19/2023 05:10 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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: 4DATE:
07/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:TIME COMPLETED:
05:13 PM
NARRATIVE
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On July 19, 2023, Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA met with Melanie Ferreira and explained the purpose of the visit.

The purpose of this case management is due to learn deficiencies during complaint investigation. LPA Martinez reviewed four out of four resident files. LPA Martinez observe all four files were missing LIC 601 Identification and Emergency information. Resident 1 (R1) LIC 602 Physician Report is not signed or dated by the resident or responsible party. R1's LIC 602 Physician report needs to be updated to reflect current health care needs. Also, R1's current LIC 602 Physician Report has conflicting information in regards to ambulatory status. The LIC 602 Physician report states R1 is bed bound, and the facility does not have a bedridden license. However, R1 does have very limited mobility. At this time, R1 needs to be reassessed in regards to mobility and ambulatory status. A new LIC 602 Physician Report with updated ambulatory status should be emailed to LPA Martinez by July 28, 2023 by 5 PM. In addition, R1 requires a reassessment due to health care changes. Resident 3 (R3) LIC 602 Physician's Report is not signed or dated by the resident or responsible party. Resident 4 (R4) LIC 602 Physician's Report was not signed or dated by the resident or responsible party.

Moreover, a LIC 500 personnel schedule has been requested by LPA Martinez on July 19, 2023. LPA Martinez has requested an Administrator work duty schedule. This work schedule shall entail information in regards to Administrator duties; number of hours that are needed to complete administrator duties, and a schedule when duties shall be completed. All requested documents should be emailed to LPA Martinez by July 28, 2023 5:00 PM. During to 07/19/2023 facility visit, LPA Martinez observed the Administrator providing care and supervision to residents, cleaning, and preparing/cooking meals. The Administrator did not have to sufficient time to complete scheduled Administrator duties. An informal meeting request was discussed with the Administrator, and time and date is pending. The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of the appeals rights, 809 report, and 809 D page was given to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2023
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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Document Has Been Signed on 07/19/2023 05:10 PM - It Cannot Be Edited


Created By: Avelina Martinez On 07/19/2023 at 10:27 AM
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: STEWART OAKS VILLA
FACILITY NUMBER: 342701211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2023
Section Cited
CCR
87405(a)

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87405 (a) Administrator - Qualifications and Duties.All facilities shall have a qualified and currently certified administrator...The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section.
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Administrator agrees to review work schedule and coordinate with Licensee to come up with a work schedule that will provide them time to complete their Admin duties by POC Date 07/28/2023. Work Schedule should be emailed to LPA Martinez by POC date 07/28/23 by 5PM.
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 Based on observations and interviews, the Licensee did not ensure the Administrator had sufficient amount of time to complete administrator duties. This posed a potential health and safety risk to residents in care.
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Type B
07/28/2023
Section Cited
CCR87506(a)

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87506(a) Resident Records: (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...This requirement was not met as evidence by: Based on observation and file review 4 out of 4 resident files.
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The Administrator agrees to conduct audits on all resident records by POC Date 07/28/23. LPA Martinez will conduct a POC visit to review files to ensure all files are complete.
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There were missing documents, such as, LIC 601. The files had incomplete documents, such as, LIC 602's missing signatures/dates. missing assessments. This posed 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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/19/2023 05:10 PM - It Cannot Be Edited


Created By: Avelina Martinez On 07/19/2023 at 03:00 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: STEWART OAKS VILLA
FACILITY NUMBER: 342701211

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2023
Section Cited
CCR
87463(a)

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Reappraisals 87463(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate...This requirement was not met as evidence by: Based on file review and interviews, the Licensee did not ensure
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The Administrator agrees to conduct reassessments for all residents on all residents by POC Date 08/04/23. LPA Martinez will conduct a POC visit to review files to ensure all reassessments are complete.
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R1 was reassessed when they displayed health care changes. This posed a potential health and safety risk to R1.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023


LIC809 (FAS) - (06/04)
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