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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002859
Report Date: 09/10/2024
Date Signed: 09/10/2024 01:38:01 PM


Document Has Been Signed on 09/10/2024 01:38 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:MOAIFACILITY NUMBER:
345002859
ADMINISTRATOR:FOWLER, CRAIG M.FACILITY TYPE:
740
ADDRESS:2633 CARDINAL COURTTELEPHONE:
(916) 844-5250
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:5CENSUS: 2DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Craig FowlerTIME COMPLETED:
01:35 PM
NARRATIVE
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On 9/10/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection visit utilizing the care tool. LPA met with Licensee/Administrator, Craig Fowler, and explained the purpose of the visit.

During today's visit, LPA observed one caregiver present, census of two residents in care, with one resident on hospice services. Facility is licensed for five non-ambulatory, hospice waiver of three.

File review conducted for three personnel records and two resident records. Records were not complete.
LPA provided Licensee the following copies:
  • HSC 1569.625
  • LIC 311F
  • LIC 501
  • LIC 503
LPA and Licensee conducted a medication audit and observed R1's medication list to be outdated. LPA observed Trazodone 100mg present but with old physician order of Trazodone 50mg. LPA and Licensee discussed obtaining updated medication list and keeping all updated telephone orders on file.

LPA and Licensee conducted a tour of the facility to ensure the health and safety of residents in care. LPA observed facility to have 2+ days of perishable and 7+ days of nonperishable foods. LPA observed cleaning supplies, medication and sharps to be stored inaccessible to residents in care. LPA observed fire extinguisher present with service date of 3/22/2024. LPA observed two residents in their private rooms resting.

Additionally, LPA is requesting LIC 500 and liability insurance to be emailed to LPA by 9/17/2024.

As a result of today's inspection, deficiencies were observed and cited. Please see LIC 809-Ds.

Exit interview, a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
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 3


Document Has Been Signed on 09/10/2024 01:38 PM - 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MOAI
FACILITY NUMBER: 345002859

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
(b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above as two personnel file did not have initial training documents on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee is to ensure staff are completely the required trainings.
Statement of compliance is to be submitted to LPA by POC due date.

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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/10/2024 01:38 PM - 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MOAI
FACILITY NUMBER: 345002859

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(2)
87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication audit, the licensee did not comply with the section cited above as the dosage for Trazodone on file does not match the dosage on perscription bottle, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee is to obtain an updated medication list for R1.
Licensee is to ensure all physican orders are kept on file. Licensee will submit R1's updated medication list to LPA by POC due date,
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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3