Community Care Licensing

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:	05/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:			TIME COMPLETED:	11:45 AM

SUPERVISOR'S NAME: Maribeth Senty TELEPHONE: (916) 263-4813 LICENSING EVALUATOR NAME: Melissa Parks TELEPHONE: (559) 580-5423 LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024

Document Has Been Signed on 05/23/2024 11:34 AM - It Cannot Be Edited

FACILITY NAME: LITTLE BROOK CARE HOME #3	FACILITY NUMBER: 345003014
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2024

Type B

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 in 2 out of 2 files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/06/2024
	Plan of Correction
1 2 3 4	Administrator will submit proof of annual training for S1 and S2

Type B

Section Cited

HSC

1569.69(a)(2)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. 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 in 2 out of 2 files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/06/2024
	Plan of Correction
1 2 3 4	Administrator will submit proof of initial training for S1 and S2

SUPERVISOR'S NAME: Maribeth Senty TELEPHONE: (916) 263-4813 LICENSING EVALUATOR NAME: Melissa Parks TELEPHONE: (559) 580-5423 LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024

Document Has Been Signed on 05/23/2024 11:34 AM - It Cannot Be Edited

FACILITY NAME: LITTLE BROOK CARE HOME #3	FACILITY NUMBER: 345003014
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2024

Type B

Section Cited

CCR

87458(a)

(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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 5 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/06/2024
	Plan of Correction
1 2 3 4	Administrator to submit LIC602 for R1 by POC due date

Section Cited

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

SUPERVISOR'S NAME: Maribeth Senty TELEPHONE: (916) 263-4813 LICENSING EVALUATOR NAME: Melissa Parks TELEPHONE: (559) 580-5423 LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024