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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001498
Report Date: 01/23/2024
Date Signed: 01/25/2024 04:04:58 PM


Document Has Been Signed on 01/25/2024 04:04 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/25/2024 12:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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**This report was amended on 1/25/24 due to a complaint with the same allegation being received earlier on the same day, 1/23/24. There was a separate report created for the complaint investigation. The Technical Advisory Note issued in this case management report is being replaced with a citation on the complaint investigation report.**.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management related to two recent incidents. LPA met with Toni Jones, Administrator, and explained the reason for the inspection. LPA and Administrator discussed how resident's (R1) family member was not permitted to speak to R1 by phone on two separate occasions. The Administrator stated that on 1/20/24, resident's family member called the community at approximately 8:48 pm, and was told by staff (S1) that she was not allowed to speak to resident due to resident being in a behavior, following what had taken place approximately an hour earlier, and due to recent visitation restrictions placed based on (R1's) family member's interactions with staff and others at the community.

On 1/22/24, Monday, resident's family member contacted the community at approximately 8:43 pm and asked to speak to (R1). Resident's family member was again told by staff (S1) she could not speak to (R1) due to visiting hours currently in place for the family member. The Administrator stated that (R1) was also already prepared to go to sleep at this time.

LPA discussed personal rights of (R1) and how each resident has the right to decide if they want to accept a phone call. LPA discussed how phone calls were not specifically mentioned in the recent visitation limitations placed on resident's family member. The Administrator agreed to discuss any restrictions related to phone calls with (R1's) family member.

Also discussed was how (R1's) medications had run out last night and (R1) didn't receive her noon dosage of Buspar when leaving the facility for a few hours this morning with a family member. The Administrator showed LPA documentation that the facility attempted to refill the medication on 1/8/24, 1/15/24, and on 1/17/24, but the physician denied the refill. The pharmacy delivered a 5-day supply this morning, 1/24/24.

A Technical Advisory Note is being issued today. There are no deficiencies issued in this report.
Exit interview. Copy of report provided to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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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