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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002854
Report Date: 03/27/2024
Date Signed: 03/27/2024 03:44:13 PM

Document Has Been Signed on 03/27/2024 03:44 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ALMOND GROVE ASSISTED LIVINGFACILITY NUMBER:
345002854
ADMINISTRATOR:PRICE, DARRELLFACILITY TYPE:
740
ADDRESS:6135 ALMOND AVENUETELEPHONE:
(916) 988-7506
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 78CENSUS: 60DATE:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator- Darrell PriceTIME COMPLETED:
04:00 PM
NARRATIVE
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On 03/27/24 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Talwinder Bains arrived at the facility unannounced to conduct a required 1 year inspection utilizing the care tool. LPAs met with Administrator Darrell Price and explained the purpose of the visit.

LPAs and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to residents bedrooms, kitchen, dining room, common areas, storage area, and laundry room. LPAs observed the second door of the laundry room to be unlocked and accessible to residents in care. LPAs observed required furniture, and lighting throughout the residents' bedrooms and facility. LPAs observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Hot water temperature was measured at 111 degrees Fahrenheit in a residents bathroom, which is within the required range of 105 to 120 degrees. The temperature in the facility was 75 degrees. First aid kit was completed. LPAs observed fire detectors and carbon monoxide detectors to be operable. LPAs observed the fire extinguisher, located in the dining room, which was last inspected on 12/08/2023. LPAs reviewed fire and disaster drill logs, which are conducted quarterly. LPAs observed required Licensing posters posted throughout the facility.

LPAs conducted a file review of five (5) personnel and five (5) residents records. Both personnel and resident records are incomplete. Medications are centrally stored, locked, and appear to be given per doctor order. LPAs compared medications to those being given for three (3) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR).

Deficiencies are being cited during today's inspection per Title 22 regulations.

Exit interview conducted and copy of the report and appeal rights was left at the facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 03/27/2024 03:44 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 03/27/2024 at 02:42 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ALMOND GROVE ASSISTED LIVING
FACILITY NUMBER: 345002854

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (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, LPA observed second door of laundry room which contained chemicals and cleaning supplies was accessible to residents in care which poses an immediate health, safety risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Administrator shall submit a letter of understanding of this regulation and will train all staff regarding this regulation. All POC documents are due to LPA by 03/28/24.
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:Laura Munoz
LICENSING EVALUATOR NAME:Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/27/2024 03:44 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 03/27/2024 at 02:42 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ALMOND GROVE ASSISTED LIVING
FACILITY NUMBER: 345002854

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 5 staff files did not have initial training upon hire, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Administrator shall ensure all staff have required initial training upon hire in staff records as required per this regulation. Facility shall send proof to department upon completion by POC due date 04/26/24
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out 5 staff do not have first aid certification as required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Administrator shall ensure all staff have required first aid training upon hire as required by this regulation. Facility shall send proof to department upon completion by POC due date 04/26/24
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:Laura Munoz
LICENSING EVALUATOR NAME:Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/27/2024 03:44 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 03/27/2024 at 02:42 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ALMOND GROVE ASSISTED LIVING
FACILITY NUMBER: 345002854

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 residents do not have LIC621 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Administrator shall complete pre- appraisal (LIC621) for all residents files and will send proof to the department by POC due date 04/26/24
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out 2 residents with DX dementia do not have updated LIC602 and reappraisal as required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Administrator shall complete LIC602 and reappraisal for all residents with DX dementia as required and will send proof to the department by POC due date 04/26/24
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:Laura Munoz
LICENSING EVALUATOR NAME:Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/27/2024 03:44 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 03/27/2024 at 02:53 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ALMOND GROVE ASSISTED LIVING
FACILITY NUMBER: 345002854

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
(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: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out 5 staff do not have a health screening and TB which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Administrator shall ensure that health screening and TB are completed for all staff files as required by this regulation. Facility will submit proof to the department by POC date 04/26/24
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:Laura Munoz
LICENSING EVALUATOR NAME:Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


LIC809 (FAS) - (06/04)
Page: 5 of 5