347000905-8-8-2024-27-AS-PLEE-D7XULY-20240808154131

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347000905
Report Date: 08/08/2024
Date Signed: 08/08/2024 03:43:38 PM

Document Has Been Signed on 08/08/2024 03:43 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:	BENIE LUNGAN CARE HOME		FACILITY NUMBER:	347000905
ADMINISTRATOR:	LUNGAN, BENILDA		FACILITY TYPE:	740
ADDRESS:	5420 SHORTWAY DRIVE		TELEPHONE:	(916) 394-9469
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	6	CENSUS: 5	DATE:	08/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:22 PM
MET WITH:	Benilda Lungan		TIME COMPLETED:	03:50 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	On 08/08/2024 at 12:22 PM, Licensing Program Analysts (LPAs) Pang Lee and Holly Williams arrived at the facility to conduct an unannounced annual inspection. LPAs met with Licensee Benilda Lungan. LPAs explained the purpose of today’s visit. Administrator Certificate # is 6003722740 and will expire on 05/04/2025. The current census is 5 with 3 facility staff. This facility is a single story building licensed to served 5 non-ambulatory resident or 4 non-ambulatory and 2 ambulatory residents. Residents’ northeast bedroom is approved for two ambulatory or 1 non-ambulatory residents. LPAs inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room, staff room and outside courtyards of the facility to ensure compliance with Title 22 regulations. It was observed the facility was free of odor, clean and in good repair. LPAs observed client bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPAs toured the kitchen and observed the facility had sufficient seven-day non-perishable food supplies and 2 days perishable food supplies. Hot water temperature was measured at 112.8 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is in the kitchen and was last serviced on 02/08/2024. The last fire drill was conducted on 07/20/2024. LPAs observed the facility has a has a public telephone in the kitchen. Facility thermostat observed at 74 degrees Fahrenheit. LPAs observed sharp knives kept locked and inaccessible to resident. LPAs observed cleaning solution and disinfectants in the garage made accessible to residents in care. LPAs observed the administrator removed the cleaning solution and disinfectants and placed them in a locked cabinets in the garage. Grab bars were observed to be stable and in good repair at this time. Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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 08/08/2024 03:43 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: BENIE LUNGAN CARE HOME	FACILITY NUMBER: 347000905
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468(c)(2)(A)

87468(c)(2)(A) Personal Rights (c) Licensees shall prominently post personally rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section… This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above. LPAs observed that the facility did not have a Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) posted in the facilitywhich poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2024
	Plan of Correction
1 2 3 4	Licensee agrees to post a Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) in the facility and take a picture and email LPA Lee a picture that the PUB 475 poster is posted in the facility by POC date 08/16/2024 by end of day 5:00 PM.

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC809 (FAS) - (06/04)

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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: BENIE LUNGAN CARE HOME	FACILITY NUMBER: 347000905
	VISIT DATE: 08/08/2024

NARRATIVE

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LPAs did not observe the resident shower to have a non-slip mat. During today’s visit administrator went and purchased a new non-skid mat and placed it in the resident shower. LPAs also didn’t observe the facility to have Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) posted in the facility. LPAs checked medication storage and found medication to be locked away and inaccessible to residents. LPAs reviewed and compared 3 out of 5 medication administration record (MAR) along with residents’ medications and it was all complete. LPAs asked to inspect the facility’s first aid kit and it was complete. LPAs requested client and staff files for review. LPAs reviewed 5 out of 5 client files and they were complete. LPAs reviewed 3 staff files and they were complete. LPAs interviewed 2 facility staff and 1 clients during today’s visit. LPAs reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents will be email to LPA Lee at pang.lee@dss.ca.gov by 08/12/2024 end of day 5:00 PM:

(1) LIC 308 Designation of Administrative Responsibility

(2) LIC 500 Personnel Report
(3) LIC 610 Emergency Disaster Plan
(4) Proof of Bond Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, Technical Assistance, Technical Violation and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC809 (FAS) - (06/04)

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