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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002854
Report Date: 11/26/2024
Date Signed: 11/26/2024 11:30:42 AM

Document Has Been Signed on 11/26/2024 11:30 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 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: 56DATE:
11/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Assistant Director, Tosha DeviTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 11/26/24 to do case management visit for Resident, R1. LPA met with Assistant Director, Tosha Devi and explained the purpose of the visit.

The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 11/04/24 regarding resident (R1) leaving the facility (AWOL) unattended on 11/02/24 at approximately 09:00 AM. Per incident report, it was discovered that R1 exited from main lobby door and facility was notified by one of their neighbors that R1 was located at their property around 09:30AM. R1 was brought back to the facility by staff uninjured. Facility notified R1’s doctor and family regarding this AWOL incident. R1's physician's report (LIC602) dated 01/19/24 indicates that resident has diagnosis of dementia and cannot leave the facility unassisted. Although no injuries resulted from R2’s AWOL, R1 was unable to leave the facility unassisted. Facility staff did not provide care and supervision to R1 resulting in R1 leaving the facility unassisted.

Immediate Civil penalties of $250.00 were assessed on LIC421FC today due to repeat violations of the same regulations within 12 months for Regulation 87468.2(a)(4).

Deficiencies issued are noted on the LIC809D per Title 22 Regulations.

Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted. Appeal rights were provided and copy of the report was provided.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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 11/26/2024 11:30 AM - It Cannot Be Edited


Created By: Talwinder Bains On 11/26/2024 at 06:51 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ALMOND GROVE ASSISTED LIVING
FACILITY NUMBER: 345002854

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/27/2024
Section Cited
CCR
87468.2(a)(4)

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87468.2-Additional Personal Rights of Residents in Privately Operated Facilities
(a)-In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs…this requirement is not met as evidenced by;
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Licensee /Administrator shall submit a letter of understanding of this regulation and will do all staff training regarding this incident. Furthermore, facility shall submit written plan to provide proper care and supervision for residents with elopement risk. All POC documents are due by POC date-11/27/24.

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Based on gathered information, it has been concluded that facility did not provide proper care of supervision to resident, R1 on 11/02/24 resulting R1 leaving the facility unattended which pose a immediate risk to health and safety of residents in care.
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In addition, facility shall conduct monthly training with staff till January 2025 and send copy of those documents to Department.

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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: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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