345003014-9-27-2023-59-AS-AHOD-CW3SWV-20230927141457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 345003014
Report Date: 09/27/2023
Date Signed: 09/27/2023 02:15:01 PM

Document Has Been Signed on 09/27/2023 02:15 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 #3		FACILITY NUMBER:	345003014
ADMINISTRATOR:	POP, PERSIDA		FACILITY TYPE:	740
ADDRESS:	7300 NOB HILL DR		TELEPHONE:	(916) 500-4512
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 5	DATE:	09/27/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Persida Pop, Administrator		TIME COMPLETED:	02:30 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) Angela Hood arrived at the facility unannounced on 9/27/23 to conduct a Post Licensing Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are seven (7) bedrooms and seven (7) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 116.5 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke detectors and carbon monoxide detector are hard wired and operational. Fire extinguisher and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed two (2) resident files and also reviewed two (2) staff files. Administrator has a current Administrator's Certificate #6009251740 with an expiration date of 11/11/23. As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22 Division 6, Chapter 8, deficiency is being cited on the attached 809-D page. Exit interview was conducted. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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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Document Has Been Signed on 09/27/2023 02:15 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: LITTLE BROOK CARE HOME #3	FACILITY NUMBER: 345003014
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as the two caregivers on duty did not have CPR and first aid training documentation in their personnel files, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Licensee agrees to have both caregivers complete CPR and first aid training by the POC due date of 10/11/2023. Administrator/Licensee arrived at the facility for inspection and has a current CPR and first aid certification.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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