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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000118
Report Date: 01/23/2023
Date Signed: 01/23/2023 12:07:30 PM


Document Has Been Signed on 01/23/2023 12:07 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:NUNEZ CARE HOME #2FACILITY NUMBER:
347000118
ADMINISTRATOR:NUNEZ, LEONIL AND RUBYFACILITY TYPE:
740
ADDRESS:8005 35TH AVENUETELEPHONE:
(916) 383-1437
CITY:SACRAMENTOSTATE: CAZIP CODE:
95824
CAPACITY:3CENSUS: 3DATE:
01/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Leonil NunezTIME COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management due to receiving an incident report. LPA met with facility staff and explained the purpose of the visit. LPA was later met by Administrator Leonil Nunez.

Facility staff Lionel Nunez self reported an incident that occurred with a resident on 12/27/2022. On 12/27/22, Resident 1 (R1) mistakenly took another resident's medication. "Staff reported that after [S1] initially administered [R1's] AM medications ... Staff then began to prep for another resident’s medication administration at the homes medication prep area.  During staff’s preparation of the other residents medication, 1 pill for the resident bubble pack was put into a pill cup. As staff turned to get the residents other pill bubble pack, [R1] walked by and noticed the single pill in the cup, and proceeded to take it.  When staff noticed this error, [S1] immediately asked [R1] why [R1] took the medication, [R1]replied, “I took it because it was my Multi-Vitamin pill.”  Staff immediately called the administrator and instructed staff to call 911. Resident was taken to the emergency room for observations. Resident was then later admitted for other health related issues. According to the administrator, the resident is currently doing well and has returned to the facility.

LPA interviewed Administrator Leonil and facility staff regarding policies and procedures. Administrator stated a training was conducted with all staff. The training focused on medication administration and was led by a Registered Nurse.

Per California Code of Regulations (CCR), Title 22, deficiencies were cited due to the above information. Appeal rights were provided. An exit interview was held with Leonil, and a report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023
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


Document Has Been Signed on 01/23/2023 12:07 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: NUNEZ CARE HOME #2
FACILITY NUMBER: 347000118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2023
Section Cited

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80075 Health Related Services(k)The following requirements shall apply to medications which are centrally stored:(1) Medication shall be kept in a safe and locked place that is not accessible to persons... This requirement was not met as evidenced:
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Licensee stated an all staff training was held on 01/21/23 to go over medication administrator. Licensee to send LPA a copy of the in-service sign in sheet by POC due date.
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Based on records review and interviews, the facility did not ensure resident 1 did not have access to another resident's medication, which poses a potential health and safety risk to residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2