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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001643
Report Date: 06/17/2022
Date Signed: 06/17/2022 02:50:40 PM

Document Has Been Signed on 06/17/2022 02:50 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DOSTY'S PRIVATE INCARE SERVICES IVFACILITY NUMBER:
347001643
ADMINISTRATOR:CAROLYN J. DOSTYFACILITY TYPE:
735
ADDRESS:2175 56TH AVENUETELEPHONE:
(916) 399-0287
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 6CENSUS: 6DATE:
06/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Carolyn DostyTIME COMPLETED:
03:15 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
A case management visit was conducted today by Tung Truong, Licensing Program Analyst (LPA).
LPA met with the Administrator, Carolyn Dosty

The purpose of the case management visit was to follow up on the medication error observed by Alta California Regional Center (ACRC), Liaison Support Coordinator (LSC) during Title 17 review at the home on 6/2/22. Based on the Facility Action Report (FAR) Client (C1) Risperidone was stuck in the bubble pack and was not given to C1 on 6/1/22. It was also observed that during LSC’s visit that C1 medication was taken from the wrong bubble pack day. The Monday morning dose was taken instead of the Thursday morning dose according to the bubble pack. In addition, the Special Incident Report obtained from ACRC indicated that the incident was reported to Licensing. However, LPA Truong reviewed the Facility Electric File and did not see this incident being reported.

The following deficiencies are cited. See LIC 809 D. Appeal rights provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
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 06/17/2022 02:50 PM - It Cannot Be Edited


Created By: Tung Truong On 06/17/2022 at 10:24 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DOSTY'S PRIVATE INCARE SERVICES IV
FACILITY NUMBER: 347001643

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2022
Section Cited
CCR
80075(b)(5)(B)

1
2
3
4
5
6
7
Health Related Services. Medications shall be given according to physician's directions. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator shall submit a plan of action and conducted in-service training to all those staff responsible for medication administration, including the staff members responsible for the medications errors. POC due 6/20/22.
8
9
10
11
12
13
14
Based on interviews and records review, the licensee did not ensure medications is provided to client according to physician's directions. Client C1 missed medication on 6/1/22 due to a med error by staff. This posed an immediate health/safety risk to the residents in care.
8
9
10
11
12
13
14
Type A
06/20/2022
Section Cited
CCR80061(b)(1)(E)

1
2
3
4
5
6
7
Reporting Requirement. Upon the occurrence, during the operation of the facility, of any of the events specified below... a report shall be made to the licensing agency… Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee shall review Title 22 Regulations, Section 80061 Reporting Requirement and submit a written statement stating knowledge of, understanding of regulation 80061. Correction due 6/20/22.
8
9
10
11
12
13
14
Based on interviews and records review, the licensee did not report unusual incident to Licensing as required. Medication error of Client C1 was not reqported to Licensing. This posed an immediate health/safety risk to the residents in care.
8
9
10
11
12
13
14
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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Tung Truong
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2