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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003004
Report Date: 06/13/2024
Date Signed: 06/13/2024 11:37:08 AM


Document Has Been Signed on 06/13/2024 11:37 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:LITTLE BROOK CARE HOMEFACILITY NUMBER:
345003004
ADMINISTRATOR:POP, PERSIDAFACILITY TYPE:
740
ADDRESS:8832 FAIR OAKS BLVDTELEPHONE:
(279) 289-6907
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
06/13/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Persida Pop, AdministratorTIME COMPLETED:
10:45 AM
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An informal conference was conducted at 9:30am on June 13, 2024 with Sacramento North Regional Office via Microsoft Teams. The purpose of this informal conference meeting is to address the recently issued citations. The Administrator was told that this Informal conference is a part of the Administrative Action process, and that further noncompliance may result in an elevation to a formal noncompliance conference, which could lead to a referral to the Department's legal division for possible revocation of license.

The following Licensing staff were present:
Licensing Program Analyst (LPA) Angela Hood and Licensing Program Manager (LPM) Maribeth Senty

The following facility representatives were present:
Administrator Persida Pop

The following topics were covered during today's meeting:
· Licensee has four (4) newly licensed facilities and there are concerns with compliance at two (2) locations (Little Brook Care Home and Little Brook Care Home #3).
· Administrator coverage at all facilities
· Citations issued address the following topics:
    · Observation of changes in residents’ conditions
    · Arranging timely medical treatment
    · Medications being distributed as prescribed with accurate documentation
    · Ensuring all medication remain locked and inaccessible to residents
**************************************************Continued on LIC809-C**********************************************
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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: LITTLE BROOK CARE HOME
FACILITY NUMBER: 345003004
VISIT DATE: 06/13/2024
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    · Ensuring transportation to medical appointments
    · Personal rights of residents to receive medical care
    · Eviction notices and notifying CCLD of evictions
    · Ensuring all annual training is conducted for staff
    · Ensuring all medical assessments for newly retained residents have been conducted within 1 year of admittance
· Plan of corrections have been received for all citations
· Technical Support Program referrals offered twice prior to meeting and were declined

Administrator indicated that there are no residents at Little Brook Care Home #4. Administrator stated that they have a second Administrator to assist with the three (3) facilities that currently have residents. During discussion with Administrator, it was observed that the Administrator did not have a clear understanding regarding the importance of following physician’s orders regarding dialysis appointments. The Department reiterated that it is the facility’s responsibility to ensure the residents’ medical appointment, if missed, are rescheduled within the same week or that, if scheduled transport is missed, alternative transportation is provided to the appointment. The Department discussed technical support at least 5 times during the meeting and Administrator declined. The Department will continue to offer technical support.

Administrator will continue to work with LPA to ensure the facility remains in compliance with regulations. Administrator agrees to contact LPA if Technical Support is necessary.

An exit interview was conducted and a copy of this report will be provided to the facility via email. A copy must be signed and returned to the Department.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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