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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001571
Report Date: 11/04/2024
Date Signed: 11/04/2024 11:58:43 AM

Document Has Been Signed on 11/04/2024 11:58 AM - 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:RICHBOROUGH FOUNTAIN, INC.FACILITY NUMBER:
347001571
ADMINISTRATOR/
DIRECTOR:		SALVADOR, RYANFACILITY TYPE:
735
ADDRESS:9038 RICHBOROUGH WAYTELEPHONE:
(916) 685-1194
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
11/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Josephine Singh, Facility ManagerTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 11/4/24, at 9:50am. Licensing Program Analyst (LPA) Arvin Villanueva arrived to the facility unannounced to conduct an annual required inspection. LPA initially met with one of the staff on duty (S2) and explained the purpose of the visit. The facility manager, Josephine Singh, was notified of the visit and arrived shortly after. Present during today's visit were 2 residents in care with 3 staff on duty.

LPA Villanueva and S2 toured the physical plant to ensure compliance with Title 22 regulations. The facility is a one story home located in a residential neighborhood. LPA observed 3 shared resident bedrooms, which were observed to be fully furnished, organized, and free from odors. LPA observed a shared resident bathroom in the hallway. The other bathroom is for staff use, located in staff room (bedroom #1 on the facility sketch). Resident bathroom had toilet paper, paper towels, soap, hand sanitizer, and a trash can. Hot water was measured at 108.5*degrees F. Common areas were observed to be furnished and free from odors. The facility temperature thermometer showed a reading of 72*degrees F during this visit. Medications, sharps, and cleaning supplies were observed to be locked and inaccessible to residents in care. The kitchen was observed to be clean, had a food supply to meet Title 22 requirements, and was observed to have an emergency supply of canned food items. The garage area is locked and inaccessible to residents. In the garage houses additional refrigerator and freezer. This area had extra food supplies, cleaning supplies, PPE supplies, and the washer and dryer. Technical Advisory (TA) was provided to ensure freezer temperature is maintained within regulatory standard of 0 degrees F. This was not met as evidenced by the observation of the 2 freezers where both freezers temperature were between 0 and 5 degrees F. The backyard was observed to have an area for sitting and emergency exit path were clear. Fenced and gates were observed to be in good repair. The facility has a pull alarm fire alarm and fire extinguishers with last inspection on 05/14/24. Facility maintains smoke and carbon monoxide detectors and they are tested and found operable during this visit.

LPA reviewed 3 resident files and were found to be in compliance at this time. LPA also reviewed 3 resident medications and were found to be in compliance at this time. LPA reviewed 4 staff files. 1 of 4 staff did not have current First Aid/CPR certificate. LPA also reviewed facility's Infection Control Plan, Emergency Disaster Plan and Disaster Drills record. Facility conducts monthly disaster drill.

LPA requested the following documentation: LIC 500, LIC 308, Surety Bond, and Liability Insurance.

Per California Code of Regulations (CCR) - Title 22, deficiencies are being cited today. An exit interview was held, and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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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Document Has Been Signed on 11/04/2024 11:58 AM - It Cannot Be Edited


Created By: Arvin Villanueva On 11/04/2024 at 11:29 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: RICHBOROUGH FOUNTAIN, INC.
FACILITY NUMBER: 347001571

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. During 4 of 4 staff file review, 1 of 4 staff on duty during this visit did not have current First Aid/CPR certificate which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Per discussion the facility manager to submit a statement of understading of the regulation cited above and submit a tentative date S2 will take their first aid/cpr class. POC to be submitted by due date of 11/5/24.
Per discussion, the facility manager will schedule S2 to get their first aid/cpr certificate updated and submit certificate once obtained but no later than 11/11/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
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