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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002854
Report Date: 07/18/2024
Date Signed: 07/18/2024 02:53:15 PM

Document Has Been Signed on 07/18/2024 02:53 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/
DIRECTOR:		PRICE, DARRELLFACILITY TYPE:
740
ADDRESS:6135 ALMOND AVENUETELEPHONE:
(916) 988-7506
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 78CENSUS: 58DATE:
07/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Assistant Director, Tosha DeviTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 07/18/24 to do case management visit. LPA met with Assistant Director, Tosha Devi and explained the purpose of the visit.

Incident for resident, R1- During complaint investigation (59-AS-20240228115229), LPA learned that resident, R1 was sent to hospital /ER due to Fall Incidents on 07/20/23 and on 10/12/23. Furthermore, R1 has been placed in Skilled Rehab Facility with diagnosis of trauma to left hip around 06/26/23 till 07/19/23. All these incidents for R1 should have been reported to Department as required per Title 22 Regulation, 87211 within 7 days but facility did not comply with this reporting requirement.

Incident for resident, R2- During complaint investigation (59-AS-20240624153835), LPA learned that resident, R2 had AWOL incident on 06/23/24 around 9am and R2 was found in their wheelchair 0.5 mile away from the facility unattended and unsupervised by law enforcement who notified the facility around 10am regarding R2’s AWOL incident. Although, R2 was found uninjured, R2 was sent to local hospital under 51/50 hold. This incident for R2 should have been reported to Department as required per Title 22 Regulation, 87211 within 24 hours but facility did not comply with this reporting requirement.

Based on the records reviewed and information gathered, it has been determined that the facility did not report these incidents for residents R1 and R2 to Department as required. Based on this information, citation has been issued per Title 22 Regulations as indicated on 809-D.

Exit interview conducted. Appeal Rights and copy of this report has been provided.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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 07/18/2024 02:53 PM - It Cannot Be Edited


Created By: Talwinder Bains On 07/18/2024 at 01:48 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: 07/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2024
Section Cited
CCR
87211(a)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department [...]: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident [...] (D) Any incident which threatens the welfare, safety or health of any resident [...]..This requirement is not met as evidenced by:
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Licensee /Administrator to review section 87211- Reporting Requirements and send a letter of understanding to Community Care Licensing and will conduct staff training. Additionally, licensee to ensure incident reports are filled out and faxed to CCL with confirmation. All POC documents are due by 08/01/24.
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Based on interviews and records review, the facility did not comply with the section cited above by not reporting incidents which threatened the welfare of residents, R1 and R2. This poses a potential health, safety, and/or personal rights 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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
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