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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000923
Report Date: 12/30/2020
Date Signed: 12/30/2020 11:20:45 AM

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:CARMEN'S CARE HOMEFACILITY NUMBER:
347000923
ADMINISTRATOR:NAVARRO, CARMENFACILITY TYPE:
740
ADDRESS:5392 MEADOW PARK WAYTELEPHONE:
(916) 427-1828
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 5DATE:
12/30/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carmen NavarroTIME COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Suong Teh spoke to the licensee Carmen Navaro, the facility administrator Diana Battung and staff Edmond Navarro via telephone to conduct a case management visit. Today's visit was conducted by telephone due to COVID-19 and precautionary measures. The purpose of the visit is for a health and safety visit.

On 12/17/2020 @1640 hours, Diana Battung, facility back up administrator called licensing to report 3 positive cases. The Department learned the first positive case was on 12/07/2020, but it was not reported to licensing until 12/17/2020.

On 12/23/2020, during a WebEx meeting with Alta Regional officers, licensee Carmen Navara and the Diana. Licensing discovered resident #1 (R1) left alone before he was admitted at the ER on 12/23/2020.

The following deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. A copy of this report has been emailed to the licensee was advised that a signed copy of the report shall be submitted to CCLD within 10 days of receipt of this report. Exit interview conducted.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6803
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020
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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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: CARMEN'S CARE HOME
FACILITY NUMBER: 347000923
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2020
Section Cited

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Reporting Requirements:
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate
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This requirement is not met as evidenced by: Based on records review and interview conducted. The Department learned the first positive case was on 12/07/2020, but it was not reported to licensing until 12/17/2020. This violation poses a potential health, and safety risk to residents in care.
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Type A
12/31/2020
Section Cited

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Responsibility for Providing Care and Supervision:
(a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by: d on records review and interview conducted. On 12/23/2020, staff #1 (S1) left resident #1 (R1) unattended in the ER before he was admitted. This violation poses a potential health, and safety risk to residents in care.
Type B
01/06/2021
Section Cited

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Personnel Requirements:
All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. Based on interviewed, staff #1 admitted that he was not familiar with the section 80078.
This violation poses a potential health, and safety risk to the residents in care.
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: Tuyet-Suong TehTELEPHONE: (916) 709-6803
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2020
LIC809 (FAS) - (06/04)
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