347001078-8-14-2024-27-AS-KVIA-D862UG-20240814174220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347001078
Report Date: 08/14/2024
Date Signed: 08/14/2024 05:42:33 PM

Document Has Been Signed on 08/14/2024 05:42 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:	COURTYARD TERRACE		FACILITY NUMBER:	347001078
ADMINISTRATOR/ DIRECTOR:	MAGDA LUIS		FACILITY TYPE:	740
ADDRESS:	3408 ALTA ARDEN EXPRESSWAY		TELEPHONE:	(916) 486-1281
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY: 40	TOTAL ENROLLED CHILDREN: 0	CENSUS: 39	DATE:	08/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Magda Luis		TIME VISIT/ INSPECTION COMPLETED:	05:45 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 08/14/2024, Licensing Program Analyst, (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct the annual inspection. LPA identified herself upon arrival, stated the purpose of the visit, and asked to speak to the Designated Facility Administrator. LPA spoke to Magda Luis and a brief interview followed. LPA compared guardian roster to the LIC 500 to ensure all staff were background cleared and allowed to care for residents. The two toured the facility. LPA observed 4 caregivers, the Life Enrichment Director, their assistant, 1 housekeeper, 1 maintenance worker and 2 medication technicians (med techs). LPA observed 22 residents sitting in the courtyard participating in chair exercises, puzzles and other table top games. LPA viewed approximately 9 resident rooms as they had their doors open to the main hallway. LPA inspected 4 resident rooms and observed personal care and hygiene items in drawers as well as in plain sight in 2 out of 4 of the rooms. LPA observed grab bars and non-skid matts in the bathrooms. LPA observed soap and paper towel dispensers. LPA observed bathrooms without soap in the soap dispensers and without paper towels. Administrator sought technical assistance with residents clogging plumbing with paper towels. Regulations require non-toxic soap be present in the bathrooms for residents to use. This deficiency was cited on the LIC 809D page. LPA measured the hot water and found it to be 118.1 degrees Fahrenheit and in compliance at the present time. Fire Extinguishers were last inspected on 03/19/24 by the Fire Code Safety Co. and were also in compliance.

Stephen Richardson	TELEPHONE: (916) 263-4746
Kimberly Viarella	TELEPHONE: (916) 809-5764
	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 9

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: COURTYARD TERRACE	FACILITY NUMBER: 347001078
	VISIT DATE: 08/14/2024

NARRATIVE

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LPA toured the kitchen. LPA observed food items in storage containers without dates as well as frozen foods, chicken, peas, corn, ravioli, in freezer bags also without labels or dates to ensure quality and freshness. This deficiency was cited on the LIC 809D page.

LPA entered a resident room and activated the alert button on the wall. A caregiver responded in 3 minutes and 39 seconds.

During a secondary walkthrough of the facility, the LPA observed 21 residents in the lounge watching a Talent TV show under the supervision of the Life Enrichment Coordinator and supported by 1 other caregiver.
LPA reviewed a sample of staff records and found them to be in compliance at the present time. LPA also reviewed a sample of resident files and found that 1 out of 4 residents were at risk for having hygiene items in their room. LPA observed Norisc peri-wash through the open doorway to the hallway. The room also contained Seaside Riviera hand soap. These items were prohibited by the Physicians Report as they were a risk to the resident in that room as well as to other residents in care. This deficiency was cited on the LIC 809 D page.

LPA observed the Medication Room and reviewed PRN procedures with the Med Tech on duty. LPA also inspected the First Aid kit and found it to be in compliance at the present time.

According to the California Code of Regulations, any deficiencies were cited on the LIC 809D pages. A copy of this report and Appeal rights were provided. An exit interview was conducted with the Designated Facility Administrator, Magda Luis.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/14/2024 05:42 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: COURTYARD TERRACE	FACILITY NUMBER: 347001078
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when the LPA photographed pantry items like split peas, and lentils in containers that were not dated. The LPA also observed frozen chicken, ravioli, corn and peas in freezer bags without labels or dates. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	Administrator stated that she will check receipts for food orders and will ensure items dated and packaged accordingly. This will be done for freezer, refrigerator, and all pantry items.

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.

Stephen Richardson	TELEPHONE: (916) 263-4746
Kimberly Viarella	TELEPHONE: (916) 809-5764
	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC809 (FAS) - (06/04)

Page: 2 of 9

Document Has Been Signed on 08/14/2024 05:42 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: COURTYARD TERRACE	FACILITY NUMBER: 347001078
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Section Cited

CCR

87705(g)

Residents with Special Health Needs: residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantaite that the resident cannot safelty manage the items. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when the LPA observed Advanced Repair Body Lotion, Peri-Fresh Perineal Cleanser, Johnson and Johnson baby shampoo, No Risc peri-wash, and Seaside Riviera hand soap, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2024
	Plan of Correction
1 2 3 4	Administrator stated she would assist staff in doing a sweep of the facility and removing any prohibited items from the rooms of residents who were at risk. Administrator will send an attestation signed by all the staff stating that they understand the importance of keeping toxic hygiene items away from residents at risk. This will be submitted by the close of business on 8/15/24. It will be submitted to kmberly.viarella@dss.ca.gov.

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.

Stephen Richardson	TELEPHONE: (916) 263-4746
Kimberly Viarella	TELEPHONE: (916) 809-5764
	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC809 (FAS) - (06/04)

Page: 9 of 9

Document Has Been Signed on 08/14/2024 05:42 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: COURTYARD TERRACE	FACILITY NUMBER: 347001078
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Section Cited

CCR

87307(a)(3)(D)

Physical Plan / Environemental Safety Hygiene itesm of general use such as soap and toilet paper. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above when 3 out of 4 resident bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4

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.

Stephen Richardson	TELEPHONE: (916) 263-4746
Kimberly Viarella	TELEPHONE: (916) 809-5764
	DATE: 08/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024

LIC809 (FAS) - (06/04)

Page: 8 of 9