345003012-7-17-2024-59-AS-SCAA-D79W2E-20240717165413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 345003012
Report Date: 07/17/2024
Date Signed: 07/17/2024 04:54:18 PM

Document Has Been Signed on 07/17/2024 04:54 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:	LITTLE BROOK CARE HOME #2		FACILITY NUMBER:	345003012
ADMINISTRATOR:	POP, PERSIDA		FACILITY TYPE:	740
ADDRESS:	3840 DELL RD		TELEPHONE:	(916) 514-0678
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 6	DATE:	07/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Persida Pop, Administrator		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Persida Pop, Administrator, and explained purpose of inspection. Also present were caregivers, Jayana Casas and Simone Viorica. LPA observed (1) resident working with a physical therapist who had just arrived. LPA observed (5) other residents throughout the home. Currently no residents are under hospice care. LPA and Administrator toured the interior and exterior of the facility including the common areas, (6) resident bedrooms, (3) resident bathrooms, kitchen, laundry area and office. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting throughout. Both bathrooms have the necessary grab bars, non-skid flooring. Administrator to ensure there are paper towels in any shared bathrooms and hand-washing posters are near each sink. There is sufficient 2+day perishable and 7+day non-perishable supply of food and locked sharps in the kitchen. There are locked toxins in the laundry room, and a lock will be installed under the kitchen sink to allow toxins to be stored. Medications are stored and locked in a medication cart. The inside temperature measured at 75F, and the hot water measured 115F in a resident bathroom. The water heater shows the hot water set at 120*F maximum. Fire extinguisher was last serviced on 12/8/23, and the smoke/monoxide alarms are in working order. Quarterly fire drills are conducted. Residents use a call button to inform staff they need assistance. All exit doors have alarms. There are sufficient towels/linens/blankets. PPE supplies will be brought over from a related facility. There is a gated and locked pool and a covered patio with seating. There are (2) unlocked exits. LPA reviewed (3) resident files and found them to be organized, complete and contain current documentation. Medications were reviewed for (2) residents- orders matched medications being given. The facility uses an Assisted Living software program to manage medications. Discussed how start dates should be noted on each bubble pack or medication bottle, as they are noted on the Centrally Stored Medication Record (LIC622).cont on 809C...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

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 2

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 #2	FACILITY NUMBER: 345003012
	VISIT DATE: 07/17/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

809C-1. LPA reviewed (4) staff files. All staff is cleared/associated and has current First Aid/CPR documentation. Also, staff is regularly completing required initial/annual training, through an approved on-line vendor. Documentation was on file. RCFE Administrator certificate #7002556740- exp 11/12/25.

Administrator stated she is signed up for the Administrator Portal where completed continuing educational units are uploaded to the Department's website. Administrator is also using the Department's Guardian system and is managing staff rosters. Email address of record is current as well as the land phone line. LPA obtained updated mobile phone number. Annual fees are current and were paid on-line.

LPA obtained an updated copy of insurance and requested updated copy of LIC308 and LIC500- due by 7/24/24.

There are no deficiencies issued; however, (2) Technical Advisory Notes are being issued on separate reports.

Exit interview. Copy of report provided to the Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2