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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001643
Report Date: 03/22/2023
Date Signed: 03/22/2023 03:55:32 PM

Document Has Been Signed on 03/22/2023 03:55 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:
03/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Janae RossTIME COMPLETED:
04:15 PM
NARRATIVE
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On 3/22/2023, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit regarding an incident report the Department received on 3/6/23. LPA met with facility assistant administrator Janae Ross and explained the purpose of the visit.

The purpose of this case management visit was to follow up on a concern learned through an incident report. Per incident report, staff smell smoke in client C1’s room when doing rounds checks on 3/5/23. C1’s house mate at the time of the incident stated that C1 was smoking methamphetamine in the bedroom. Based on today’s visit, it was determined that there was lack of staff supervision at the time of the incident. Client C1 and C2 reported that weekend staff don’t check on them or doing anything. Client C1 denied smoking methamphetamine in the facility but admitted to smoking marijuana.

The following deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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 03/22/2023 03:55 PM - It Cannot Be Edited


Created By: Tung Truong On 03/22/2023 at 03:16 PM
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: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2023
Section Cited
CCR
80078(a)

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80078(a) Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:
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Licensee/Administrator will provide an in-service training for all staff regarding care and supervision and submit a written statement stating knowledge of, understanding of the regulation 80078 to CCL by the POC date of 3/23/23.
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Based on interviews and records review, the licensee did not ensure that care and supervision was provided at all times. Staff did not perform care and supervision duties as required. This poses an immediate risk to clients in care.
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Licensee/Administrator will send a sign-in sheet with all staff signatures by POC due date.

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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Tung Truong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023


LIC809 (FAS) - (06/04)
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