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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001775
Report Date: 11/19/2021
Date Signed: 11/19/2021 01:26:46 PM

Document Has Been Signed on 11/19/2021 01:26 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:DEBORAH FILPULA ADULT HOMEFACILITY NUMBER:
347001775
ADMINISTRATOR:DEBORAH FILPULAFACILITY TYPE:
735
ADDRESS:10090 LINCOLN VILLAGE DRIVETELEPHONE:
(916) 361-0329
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY: 6CENSUS: 6DATE:
11/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jacob FlipulaTIME COMPLETED:
01:45 PM
NARRATIVE
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On 11/19/21 at 11:00am Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management Inspection to address additional concerns regarding an incident report received on 11/18/21 regrading R1 (see confidential name list, LIC 811 dated 11/19/21).

LPA met with Staff members S1 and S2 and conducted interviews with the two staff members. LPA also conducted a walk through of the facility and observed no bath mats or non-slip surfaces in the bathroom where R1 had fallen and received a laceration above his right eye which required medical attention and the laceration was glued closed by a medical professional.

Based on the interviews conducted, LPA's observations and documentation reviewed, the department has determined the facility did have a bath mat but was not being used at the time of the incident. Additionally, the department determined R1 should have been assessed by a medical professional as soon as it was determined R1 had obtained a head injury as a result of the fall to rule out any neurological injuries such as concussion.

The following deficiencies are cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with the licensee. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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 11/19/2021 01:26 PM - It Cannot Be Edited


Created By: Kevin Gould On 11/19/2021 at 12:52 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: DEBORAH FILPULA ADULT HOME
FACILITY NUMBER: 347001775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2021
Section Cited
CCR
80088(e)(3)

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Furniture, Fixtures, Equipment, and Supplies: All toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.
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Facility will purchase and utilize rubberized bath mats and non-slip surcaces on the bathroom floor to prevent slips and falls on the bathroom tile.
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this requirement was not met as evidenced by LPA's observations of no bath mat or non-slip surfaces in place at the time of incident and statements obtained regarding R1's behaviors including attempts to exit the shower often while wet without drying which poses an immediate health and safety risk to residents in care.
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Type B
11/24/2021
Section Cited
CCR85075(b)

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Health-Related Services: The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs. This requirement was not met as evidenced by R1 sustaining a head injury that was not assessed by a physician or medical professional prior to
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Facility will submit a written plan for assessing head injuries for residents in care and will submit to the department for approval, once approved all staff will be trained on the new plan and signature of the staff being trained will be submitted to the department.
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R1 going to day program which poses a potential health, safety and personal rights risk to residents in care.
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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:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021


LIC809 (FAS) - (06/04)
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