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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000120
Report Date: 06/02/2023
Date Signed: 06/02/2023 10:59:04 AM


Document Has Been Signed on 06/02/2023 10:59 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CAJUCOM CARE HOME #2FACILITY NUMBER:
347000120
ADMINISTRATOR:EDILBERTO Z CAJUCOMFACILITY TYPE:
740
ADDRESS:3030 EASTERN AVETELEPHONE:
(916) 489-1771
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:12CENSUS: 7DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Lupe CajucomTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 06/02/2023 at 8:30 AM. LPA met with Lupe Cajucom and stated the purpose of today’s visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate  and expires on 07/24/2024. The facility is licensed for twelve residents. The facility can accept six non-ambulatory residents and six ambulatory residents. There are currently seven residents who reside at this facility.

LPA Martinez toured the facility with Lupe Cajucom on 06/02/2023 at 8:30 AM.

The facility was furnished and in good repair. The facility water temperature measured at 108 degrees, and the facility temperature measured at 76 degrees. The facility fire extinguisher was in good repair, and the facility has installed a fire sprinkler system. The smoke detectors are in good repair. The facility had an adequate food supply, and kitchen sink was in good repair. The facility has a designated patio area for resident. LPA Martinez reviewed seven resident files, and they were up to date. LPA Martinez reviewed three staff files, and files were missing first aid. LPA Martinez reviewed two resident medication files, and it was learned Medication Administration Records (MAR) were not being filled out. However, staff 1 reported medication was being administered daily. It was also learned one resident 1 (R1) eloped from the facility. The elopement was reported to law enforcement and responsible parties. The Licensee reported they will continue to follow up with responsible parties.

As a result of this visit, the following deficiencies were cited, per California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of the 809 report, 809-D page, and appeals right given were given to the facility at the end of visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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 3


Document Has Been Signed on 06/02/2023 10:59 AM - 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: CAJUCOM CARE HOME #2
FACILITY NUMBER: 347000120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2023
Section Cited
CCR
87411(a)

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87411(a) Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidence by:
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Licensee agrees to provide an update to LPA Martinez on 06/05/2023 via phone call. Licensee agrees to continue to follow up with R1's responsible party and law enforcement, and provide update to LPA Martinez via phone call on POC Date 06/05/2023 prior to 5PM.
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Based on interviews and record review. The Licensee did not ensure adequate supervision of residents in care. R1 AWOL'd from the facility. This poses an immediate health and safety risk to the R1 in care.
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Type B
06/23/2023
Section Cited
CCR87411(c)(1)

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Personnel Requirements - General 87411(c)(1):All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69...
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Licensee agrees to conduct first aid training for all staff by POC date 06/23/2023. Licensee will email firs aid documents to LPA Martinez by POC date on 06/23/2023.
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Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidence by: Based on file review S1, S2, S3 were missing first aid. This posed 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/02/2023 10:59 AM - 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: CAJUCOM CARE HOME #2
FACILITY NUMBER: 347000120

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
CCR
87465(h)(6)

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Incidental Medical and Dental Care 87465(h)(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year...This requirement was not met as evidence by:
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Licensee agrees to conduct medication training by POC Date 06/23/2023. Licensee agrees to email training documents to LPA Martinez by POC date 06/23/2023 by 5 PM.
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based on file review and interviews, the licensee did not ensure R1 and R2 MAR was filled out. This posed 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3