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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001879
Report Date: 07/10/2023
Date Signed: 07/10/2023 12:48:18 PM

Document Has Been Signed on 07/10/2023 12:48 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ED DAVID CARE HOME #1FACILITY NUMBER:
347001879
ADMINISTRATOR:MARINA DAVIDFACILITY TYPE:
735
ADDRESS:7125 CANAVERAL WAYTELEPHONE:
(916) 332-2218
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 6CENSUS: 6DATE:
07/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Grace Woodford TIME COMPLETED:
01:10 PM
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On 07/10/23,Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 06/26/23. LPA met with Administrator Grace Woodford and explained the reason for the visit.

Alta California Regional Center Special Incident Report submitted by facility on 06/27/23 to CCL stated that Staff (S1) did not give 2 scheduled medications to R1 on the evening of 06/26/23.

Based on incident report, staff interviews, medication record review and observation from the facility, R1 was supposed to receive, Quetiapine 150 mg ( 1 tablet ) and Citalopram 20 mg tablet ( 1 tablet ) on the evening of 06/26/23 but staff did not give these 2 medications to R1 as ordered by R1s physician .Facility noticed the medication error on 06/27/23 in the morning time and found out that these 2 medications were left in bubble pack. Facility notified R1s physician, CCL, ALTA and other agencies regarding this medication error on 06/27/23. Per facility’s reports, there were no changes to R1s health due to this medication error and R1 was at their baseline. Based on this information, it was determined that facility did not administer these 2 medications to R1 which poses a immediate health and safety risk to residents in care.


Deficiency is cited per California Code of Regulations, Title 22, and listed on LIC 809D.

Failure to submit Proof of Correction (POC) by Plan of Correction date may result in civil penalties.

Exit interview conducted. Appeal rights provided. Copy of the report left at facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2023
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 07/10/2023 12:48 PM - It Cannot Be Edited


Created By: Talwinder Bains On 07/10/2023 at 12:38 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ED DAVID CARE HOME #1
FACILITY NUMBER: 347001879

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2023
Section Cited
CCR
80075(b)(5)(B)

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80075 Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
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Licensee/Administrator agreed to submit a self-certification of understanding the regulation ,80075 (b)(5))B) and providing medication training for all staff regarding medication administration and submit proof to LPA by POC date- 07/11/23.
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Based on record review from the facility, on 06/26/23, facility staff (S1) did not give 2 medications Quetiapine 150 mg ( 1 tablet ) and Citalopram 20 mg tablet ( 1 tablet ) to R1 as ordered by R1s physician, which poses an immediate health and safety 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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023


LIC809 (FAS) - (06/04)
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