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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000923
Report Date: 12/27/2023
Date Signed: 12/27/2023 03:01:17 PM


Document Has Been Signed on 12/27/2023 03:01 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 HOMEFACILITY NUMBER:
347000923
ADMINISTRATOR:NAVARRO, CARMENFACILITY TYPE:
740
ADDRESS:5392 MEADOW PARK WAYTELEPHONE:
(916) 427-1828
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 4DATE:
12/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Carmen Navarro TIME COMPLETED:
03:15 PM
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On 12/27/2023 at 12:10 PM Licensing Program Analyst (LPA) Pang Lee arrived at facility location unannounced. LPA Lee was met by care staff Cynthia Navarro and explained the purpose of today’s visit. Care staff then called administrator Carmen Navarro. Administrator arrived approximately 40 minutes later.

Today’s visit is in regard to a recent facility action report (FAR) from Alta Regional Center. A brief tour of the facility was conducted. LPA reviewed a copy of the FAR that was received from Alta. Upon review of the FAR, it was learned that client 1 (C1) was seated in a wheelchair near a window with a gait belt attached. When care staff was questioned regarding the gait belt, it was learned that there was no medical prescription for the use of the gait belt nor behavioral support documentation for its use. It was also learned that the facility was given corrective action plans for deficiencies cited under CCR Title 17 section 56054(a)(1) and section 56054(a)(3). It was also learned that the facility was placed on sanctions by ALTA Regional until all corrective action plans are completed in full. During today’s visit administrator, Carmen was able to provide LPA Lee a copy of a note from (C1) Physical Therapist, Jolie Gonzalez authorizing (C1) using the gait belt. It was also learned that Jolie have trained (C1) caregivers to use the gait belt to assist (C1) with transfers and ambulation. Per Jolie the belt is donned around (C1) waist to help with balance to prevent a fall and is not attached to (C1) chair to prevent (C1) form getting up or used in anyway as a restraint.

Based upon review of information obtained Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
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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