342701230-5-21-2024-27-AS-PLEE-D5GQ9L-20240521115832

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701230
Report Date: 05/21/2024
Date Signed: 05/21/2024 11:58:40 AM

Document Has Been Signed on 05/21/2024 11:58 AM - 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:	SACRAMENTO SENIOR LIVING		FACILITY NUMBER:	342701230
ADMINISTRATOR:	LEWIS, SALOTE		FACILITY TYPE:	740
ADDRESS:	6825 BENDER CT		TELEPHONE:	(510) 710-5707
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95820
CAPACITY:	6	CENSUS: 5	DATE:	05/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:27 AM
MET WITH:	Salote Lewis		TIME COMPLETED:	12:10 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	On 05/21/2024 at 8:28 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care giver, Asena Motubula who then called administrator Salote Lewis to informed that CCLD is present. Administrator arrived to the facility approximately 30 minutes later. LPA Lee explained the purpose of today’s visit. Administrator Certificate # 6062098740 expires on 08/08/2024. The current census is 5 with 1 facility staff. This facility is a single story building licensed to served six (6) non-ambulatory residents and approved for 2 hospice waivers. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, residents’ bedrooms, residents’ bathrooms, laundry room, staff room, garage, and outside courtyards of the facility to ensure compliance with Title 22 regulations. It was observed the facility was free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee toured the kitchen and observed the facility had sufficient seven-day non-perishable food supplies. It was observed that two-day perishable food supplies were not sufficient for 5 residents in care. Hot water temperature was measured at 122.1 degrees Fahrenheit in resident bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit. During today’s visit administrator adjusted the water temperature and it then was measured at 114.1 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 04/03/2024. The last fire drill was conducted on 02/02/2024. LPA Lee observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. The facility has an infection control plan and an emergency disaster plan. Facility thermostat observed at 70 degrees Fahrenheit. LPA Lee observed toxins located in the garage were kept locked and inaccessible to residents. Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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 05/21/2024 11:58 AM - 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: SACRAMENTO SENIOR LIVING	FACILITY NUMBER: 342701230
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. Records reviewed indicated that 1 out of 4 MAR log was inaccurate. Resident 1 (R1)’s Capsaicin 0.075 cream medication was not documented on the MAR. Direct caregiver and administrator stated that (R1)’s cream is applied on (R1); however, it is unclear if (R1)'s Capsaicin cream is being apply since it is not documented. Per physician's order (R1)'s Capsaicin cream is to be apply four times a day for pain. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	Administrator will ensure to accurately maintain resident's MAR log and ensure that all resident's medications are given to residents per physician's order. Administrator will review the regulation cited today and provide a statement of acknowledgement of reading and understanding the regulation cited. Administrator will also email LPA Lee (R1)'s MAR for the month of May. POC is due to LPA Lee by 05/31/2024 by 5:00 PM end of day.

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: SACRAMENTO SENIOR LIVING	FACILITY NUMBER: 342701230
	VISIT DATE: 05/21/2024

NARRATIVE

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LPA Lee observed sharp knives kept locked and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed and compared 4 out 5 medication administration record (MAR) along with residents’ medications. Records reviewed indicated that 1 out of 4 MAR log was inaccurate. Resident 1 (R1)’s Capsaicin 0.075 cream medication was not documented on the MAR. Per physician's order (R1)'s Capsaicin cream is to be apply four times a day for pain. Direct caregiver and administrator stated that (R1)’s cream is applied on (R1); however, it is unclear if (R1)'s Capsaicin cream is being apply since it is not documented. The first aid kit was checked, and it was complete. LPA Lee requested resident and staff files for review. LPA Lee reviewed 5 out of 5 resident files and 3 out of 3 staff files and they were 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 05/27/2024 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, Technical Assistant and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

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