345002978-10-30-2024-59-AS-DAWL-DAJPXJ-20241030114221

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 345002978
Report Date: 10/30/2024
Date Signed: 10/30/2024 11:42:39 AM

Document Has Been Signed on 10/30/2024 11:42 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:	PINNACLE HOME CARE 2		FACILITY NUMBER:	345002978
ADMINISTRATOR/ DIRECTOR:	DAVTYAN, LUSINE		FACILITY TYPE:	740
ADDRESS:	4500 HUMMINGBIRD CIRCLE		TELEPHONE:	(916) 771-9420
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY: 6		CENSUS: 5	DATE:	10/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Judelyn Cababing, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

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On October 30, 2024 at 9:30am, Licensing Program Analyst (LPA) De Anna Williams-Lyons arrived unannounced to conducted an Annual Inspection of the facility to ensure compliance with Title 22 regulations. LPA Lyons met with Judelyn Cababing, Administrator, who assisted LPA in today’s inspection. The Administrator certificate expires 12/3/2025. The current census is 5. The facilities Administrator’s Certificate, Emergency Disaster Plan, Resident’s Rights and Facility Sketch was available for viewing. The room temperature was 70 degrees F which is within range.

LPA inspected the interior and the exterior of the facility including the common living spaces, the kitchen, resident bedrooms and bathrooms. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day

The facility is a one-story home. Living rooms, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident bedrooms and bathrooms were toured. There are 4 Bedrooms. All rooms had the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. Hot water temperature is 109 degrees F. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer was present and operating properly. Toxic substances, laundry and cleaning supplies were inaccessible.

To continue see 809-C...

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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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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: PINNACLE HOME CARE 2	FACILITY NUMBER: 345002978
	VISIT DATE: 10/30/2024

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First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards.

There’s a closet for resident’s medication. Medication cabinet was locked. The facility Medication Administration Record was reviewed as well as the dispensing log.

LPA reviewed 2 resident files and 2 staff files. Resident's Records reviewed indicated emergency contacts, Assessments, Admission Agreements and Physician's Reports were all current and up to date. Staff records reviewed revealed current First Aid & CPR certificates, Health Screenings and Emergency Contacts were all up to date and the facility is conducting staff training as required.

Administrator and LPA completed the Infectious Control Questionnaire with no issues or concerns. LPA was not able to interview the residents due to all were sleeping. The only staff that was at the facility was unavailable to be interviewed.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were observed today.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file. Administrator shall submit the listed documents to Licensing no later than November 30, 2024.

An exit interview was conducted and a copy of this report was given to Judelyn.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

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