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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002972
Report Date: 02/09/2024
Date Signed: 02/09/2024 05:47:13 PM


Document Has Been Signed on 02/09/2024 05:47 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:GOOD SAMARITAN CARE FACILITYFACILITY NUMBER:
345002972
ADMINISTRATOR:DANIELYAN, DANIELFACILITY TYPE:
740
ADDRESS:4406 BARRETT ROADTELEPHONE:
(916) 458-2615
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Daniel DanielyanTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an annual inspection utilizing the full CARE tool. LPA met with caregiver and explained the purpose of the visit. Caregiver contacted Administrator who stated he will be coming to the facility shortly. Today's census is four residents in care,

LPA and Caregiver conducted a tour of the facility. Areas toured included but not limited to: four residents rooms, two bathrooms, and the common areas. After inspection was conducted, Administrator arrived to the facility to discuss deficiencies with LPA. During inspection, LPA observed medications to be in four out of four residents rooms. LPA observed cleaning supplies such as windex and clorox spray to be placed throughout the facility, easily accessible to residents in care. LPA observed fire extinguisher to last be serviced on 11/30/2022. LPA informed Administrator fire extinguishers should be serviced annually to ensure it is in good condition. LPA observed power tools to be in the garage, LPA informed Administrator dangerous items should be locked and secured at all times. LPA observed S1 is not have a fingerprint clearance at the facility. LPA observed R4's room to be missing a bed, LPA informed Administrator an exception request should have been submitted as no bed in the room is noncompliance to California Code Regulation, Title 22.

LPA conducted a resident file review and observed R1 and R2's LIC 602 to be incomplete. LPA observed R3 and R4 to have no LIC 602 on file as Administrator was not aware that all residents are to have the following documents. LPA conducted a personnel file review and observed no documentation of staff training. Additionally, LPA observed only one out of seven staff to have First Aid and CPR training.

CARE inspection tool completed and deficiencies was observed. Please see LIC 809-Ds. Today's visit, civil penalties assessed.

LPA requested a copy of facility's liability insurance, LIC 500 and LIC 308 by Monday February 12, 2024.

Exit interview conducted and a copy of the report and appeal rights was emailed to Administrator.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
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 02/09/2024 05:47 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: GOOD SAMARITAN CARE FACILITY
FACILITY NUMBER: 345002972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

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 as LPA observed two fire extinguishers to be last serviced 11/30/2022 which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee is to service fire extinguishers immediately and submit proof of service.
Additionally, Licensee will submit a plan on how to service fire extinguishers in a timely manner to be in compliance to fire safety.
Type B
Section Cited
CCR
87458(a)
87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

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 in two out of four residents did not have a LIC 602 on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee is to contact residents' primary care physicians for complete LIC 602.

Informal meeting will be scheduled to discuss this matter.
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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 02/09/2024 05:47 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: GOOD SAMARITAN CARE FACILITY
FACILITY NUMBER: 345002972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 as LPA observed the presence of power tools, cleaning supplies and medications to be unsecured and accessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2024
Plan of Correction
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Cleaning supplies were immediately recovered and stored. Licensee will stored power tools immediately. All medications will be secured.

This matter will be discussed in an informal office meeting.
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and file review, the licensee did not comply with the section cited above as LPA observed S1 to be working without a criminal clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2024
Plan of Correction
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S1 is to be removed from schedule and facility immediately.
Licensee is to complete fingerprint process LIC 9163 for S1.

This matter will be discussed during an informal office meeting.
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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 02/09/2024 05:47 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: GOOD SAMARITAN CARE FACILITY
FACILITY NUMBER: 345002972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
ยง1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following:
(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 only 1 out of 7 staff has a CPR/first aid certificate on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Staff are to complete first aid/CPR training.

This matter will be discussed during an informal office meeting.
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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 02/09/2024 05:47 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: GOOD SAMARITAN CARE FACILITY
FACILITY NUMBER: 345002972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(A)
87307 Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:
(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:
(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary.

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 as LPA observed R4's to have no bed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee will submit exception request is to be submitted for R4.

This matter will be discussed during an informal office meeting.

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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5