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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002824
Report Date: 09/15/2022
Date Signed: 09/15/2022 04:11:38 PM

Document Has Been Signed on 09/15/2022 04:11 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:LIVING WATER THEFACILITY NUMBER:
345002824
ADMINISTRATOR:LAQUAGLIA, MARLANAFACILITY TYPE:
740
ADDRESS:7800 CLAYPOOL WAYTELEPHONE:
(916) 425-9266
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 2DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Grace Gunawan, Administrator, Herlina Pranoto, Administrator, and Gabrielle Hanggono, TIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Herlina "Lina" Pranoto, and Triyeni "Yeni" Sulistiani Oey, caregivers and explained purpose of inspection. Gabrielle Hanggono, caregiver arrived around 11:40 am and Grace Gunawan, Administrator, arrived at 12:00 pm. LPA observed (1) resident watching television in the common area and was informed (1) resident was at a doctor appointment. The second resident returned to the facility around 12:25 pm. Currently, there is a pending ownership change. LPA spoke to current licensee, Marlana, by phone, at the start of the inspection, who indicated she was not able to attend today's inspection. Neither resident is receiving hospice services as the current license does not have an approved hospice waiver.

Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA and Administrator toured the interior and exterior of the facility including the common areas, resident bedrooms (5), resident bathrooms (4.5), kitchen, staff room (1)and garage/laundry area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. Administrator to purchase trash cans with lids for the bathrooms. LPA observed sufficient 2+day perishable and 7+day non-perishable food and a first aid kit. LPA observed locked medications in a separate cabinet and locked toxins in the garage. LPA observed unlocked sharps, toxin (soap) in the kitchen and unlocked staff vitamins near the kitchen area and (1) unlocked bottle of vitamins in resident (R1) room. LPA observed the smoke/monoxide detectors to be working and the fire extinguisher to have been last serviced 3/14/2022. A final fire clearance was issued on 9/2/2022 as part of pending license. LPA observed Administrator certificate #6063758740- exp 8/24/2024 to be displayed.
cont on 809C..
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: LIVING WATER THE
FACILITY NUMBER: 345002824
VISIT DATE: 09/15/2022
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 809C.. LPA observed (1) unlocked outside gate from the inside and observed sufficient space outside with shade coverings. There is a fountain that is not currently operating. There are no bodies of water or a pool.

LPA observed resident binders to be complete with current physician reports and observed additional documentation for the facility on file, including a completed Mitigation Plan.

Discussed vaccination status of residents/staff, eligibility for boosters and visitation protocols. All staff are cleared/associated or requested to be associated. A booster flyer was left with the facility.

LPA discussed CCLD website and various links available for information. LPA assisted Administrator in requesting PINs be emailed to her and agreed to update email contact for the facility.

The infection control domain of the annual tool was completed during today's inspection. LPA provided some sanitizers, gowns and gloves from Regional Office supply during today's inspection. LPA to send COVID posters by email and some PPE training links. Administrator to update visitor sign-in log to include contact tracing, signs/symptoms, vaccination information.

Per California Code of Regulation, Title 22, Division 6, the following (1) deficiency is cited. See 809D for citation issued. Failure to correct the citation by the due date may result in a penalty being assessed.

Exit interview. Copy of report and appeal rights to be emailed.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
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Document Has Been Signed on 09/15/2022 04:11 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 09/15/2022 at 02:58 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: LIVING WATER THE
FACILITY NUMBER: 345002824

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1&2)

(f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in multiple knives, (1) toxins and vitamins were not secured, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Administrator and caregivers immediately removed the unlocked sharps, botttle of dish soap and over the counter vitamnins and secured them out of reach of the residents. Administrator stated magnetic cabinet locks will be installed today. and agreed to send a photo of the locks once installed. Photo to be sent by text, email or fax by COB 9/16/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Maribeth Senty
LICENSING EVALUATOR NAME:Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


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