<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001629
Report Date: 02/28/2024
Date Signed: 02/28/2024 11:44:02 AM


Document Has Been Signed on 02/28/2024 11:44 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:MARIA'S HOME CAREFACILITY NUMBER:
347001629
ADMINISTRATOR:ANDREI COSTEAFACILITY TYPE:
740
ADDRESS:5914 CANARY DRIVETELEPHONE:
(916) 344-5487
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY:6CENSUS: 5DATE:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator- Andrei CosteaTIME COMPLETED:
11:45 AM
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 02/28/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with staff, Marcia Waite, and explained the purpose of the visit. LPA requested for staff to notify Administrator of LPA's presence at the facility. Administrator, Andrei Costea arrived at the facility shortly after.

LPA and staff conducted a tour of the facility. Areas toured included but not limited to the kitchen, dining room, five (5) residents bedrooms, bathrooms, common areas and backyard. LPA observed the facility to have sufficient food supplies for seven (7) day non-perishable and two (2) day perishable. LPA observed toxins, knives and centrally stored medications to be locked and inaccessible to residents in care. All required Licensing posters are present in common areas in the facility. Hot water temperature was measured at 112.8 degrees Fahrenheit at the kitchen sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 72 degrees. Fire extinguishers was last inspected on 02/08/24.

LPA conducted a file review of three (3) resident files. LPA observed one (1) resident file to be missing the medical assessment. LPA reviewed two (2) personnel records. LPA observed one (1) personnel file to be incomplete with no annual training.

LPA requested a copy of the current liability insurance to be sent to LPA Ratajczak by 03/13/24.

LPA completed the full care tool and deficiencies was observed. Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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 2


Document Has Been Signed on 02/28/2024 11:44 AM - 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MARIA'S HOME CARE
FACILITY NUMBER: 347001629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 2 staff files does not have annual trainings which poses a potential health, safety risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
1
2
3
4
Licensee will conduct an annual training with staff by the POC due date and submit to LPA Ratajczak a list of topics covered as well as staff signatures indicating who has completed the training.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 3 resident files were missing a medical assessment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
1
2
3
4
Licensee is to notify LPA Ratajczak once R1's LIC602 is completed.
Licensee is to submit a statement of understanding that all residents in care are to have a completed LIC602 in their records and that LIC602s need to be updated annually.
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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2