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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000702
Report Date: 08/28/2024
Date Signed: 08/28/2024 03:08:51 PM


Document Has Been Signed on 08/28/2024 03:08 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:INDOCARE HOUSE 1FACILITY NUMBER:
347000702
ADMINISTRATOR:LOMENDEHE, PAULFACILITY TYPE:
740
ADDRESS:8278 NEWFIELD CIRCLETELEPHONE:
(916) 682-5461
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Jendri KolibuTIME COMPLETED:
03:45 PM
NARRATIVE
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On 8/28/24 at 1:40pm Licensing Program Analyst (LPA) Kevin Gould arrived at Indocare House 1 for the purpose of conducting a required 1 year annual inspection. LPA met with staff, Jendri Kolibu and together conducted a tour of the home.

LPA and staff evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor and clean LPA observed one broken door on the back bedroom that is in need of repair replacement. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 113 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA observed R1's resident file and observed two conflicting physician reports regarding the resident's non-ambulatory bedridden status written days apart. LPA has informed the facility that R1's physician report must be updated and to contact LPA once completed to determine if the resident is able to reside in the facility due to the facility's fire clearance.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 9020 client roster and current administrator certificate.

Per California Code of Regulations, Title 22 the following deficiency is cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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 08/28/2024 03:08 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: INDOCARE HOUSE 1
FACILITY NUMBER: 347000702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation the licensee did not comply with the section cited aboveas the resident's door to the back bedroom is broken and no longer provides privacy for resident in back room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2024
Plan of Correction
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Facility has agreed to repair or replace door by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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