347000923-12-5-2023-27-AS-PLEE-CY8VFU-20231205152431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347000923
Report Date: 12/05/2023
Date Signed: 12/05/2023 03:24:46 PM

Document Has Been Signed on 12/05/2023 03:24 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:	CARMEN'S CARE HOME		FACILITY NUMBER:	347000923
ADMINISTRATOR:	NAVARRO, CARMEN		FACILITY TYPE:	740
ADDRESS:	5392 MEADOW PARK WAY		TELEPHONE:	(916) 427-1828
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	6	CENSUS:	DATE:	12/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Carmen Navarro		TIME COMPLETED:	03:30 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 12/05/2023 at 1:05 PM Licensing Program Analysts (LPAs) Pang Lee and Arvin Villanueva arrived at the facility to conduct an unannounced annual inspection. LPAs met with direct care staff, Cynthia Navarro, who then called administrator, Carman Navarro. Administrator arrived approximately 20 minutes later. LPAs explained the purpose of the visit. Administrator assisted with today’s visit. Administrator certificate # is 6022122740 and will expire on 12/14/2024. The current census is 4 with 2 facility staff. This facility is a single story building licensed to serve six (6) 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 and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPAs observed the facility to be free of odor, clean and in good repair. LPAs observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPAs toured the kitchen and observed sufficient two-day perishable and seven-day non-perishable food supplies. LPAs also observed hygiene products stored in the pantry with the non-perishable food. Hot water temperature was measured at 110.0 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in common area and was last serviced on 01/12/2023. The last fire drill was conducted on 11/18/2023. LPAs observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. The facility has an infection control plan and an emergency disaster plan. Facility thermostat observed at 72 degrees Fahrenheit. LPAs observed toxins located in laundry and kept locked and inaccessible to residents. LPAs observed sharp knives kept locked and inaccessible to clients. 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: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARMEN'S CARE HOME	FACILITY NUMBER: 347000923
	VISIT DATE: 12/05/2023

NARRATIVE

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LPAs observed the sliding door and window in the recreation room are missing window screens. LPAs checked medication storage and found medication to be locked away and inaccessible to residents. LPAs reviewed and compared 4 out of 4 medication administration record (MAR) and it was complete. The first aid kit was checked and contained all the required components. LPAs requested residents and staff files for review. LPAs reviewed 4 out of 4 resident files and 4 out of 4 staff files and they were complete. 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 (pang.lee@dss.ca.gov) by 12/15/2023 by 5:00 PM by end of day:

(1) LIC 308 Designation of Administrative Responsibility

(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) Surety Bond

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency 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, 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: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 12/05/2023 03:24 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: CARMEN'S CARE HOME	FACILITY NUMBER: 347000923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

87303(c) Maintenance and Operation All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the Licensee did not ensure that the sliding door and window in the recreation area had window screens, which poses/posed a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that window screens will be placed in the recreation room for the sliding door and the window. Licensee will send pictures of the installed window screens and receipt of purchased to LPA Lee by POC date 12/15/2023 by 5:00 PM 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: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4