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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001879
Report Date: 08/03/2023
Date Signed: 08/03/2023 11:14:04 AM

Document Has Been Signed on 08/03/2023 11:14 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: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:
08/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Administrator, Marta Blanco TIME COMPLETED:
11:25 AM
NARRATIVE
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On 08/03/23, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 07/13/23 and 07/14/23. LPA met with Administrator Marta Blanco and explained the reason for the visit.

Alta California Regional Center Special Incident Report submitted by facility on 07/17/23 to CCL stated that Staff (S1) did not give 1 scheduled medication to R1 on the morning of 07/13/23 and 07/14/23.

Based on incident report, staff interviews, medication record review and observation from the facility, R1 was supposed to receive, Amlodipine 5 mg( 1 tablet ) on the morning of 07/13/23 and 07/14/23 but staff did not give this medication to R1 as ordered by R1s physician .Facility noticed the medication error on 07/16/23 and found out that this medication was left in medication container for R1. On 07/16/23, Facility staff told administrator that they found 2 loose pills of Amlodipine 5mg in R1s medication container, and these 2 pills were missed and not administered per physician’s order to R1 for 07/13/23 and 07/14/23. Facility notified R1s physician, CCL, ALTA and other agencies regarding this medication error on 07/17/23. Per facility’s reports, there were no changes to R1s health due to this med error and R1 was at their baseline. Based on this information, it was determined that facility did not administer this medication to R1 which poses a immediate health and safety risk to residents in care.


Deficiencies are cited pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) and documented on the attached LIC809D. Immediate Civil penalty of $250.00 was assessed on LIC421FC today due to repeat violation of the same regulation within 12 months.

The report was reviewed, appeal rights and a copy of this report was left at the facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2023
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 08/03/2023 11:14 AM - It Cannot Be Edited


Created By: Talwinder Bains On 08/03/2023 at 08:20 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
, 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: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2023
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- 08/04/23.
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Based on record review from the facility, on 07/13/23 and 07/14/23, facility staff (S1) did not give 1 medication Amlodipine 5mg
( 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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Licensee/Administrator will provide weekly medication training for all staff regarding medication administration and submit proof to department for next 90 days.

Immediate Civil penalty of $250.00 was assessed today.

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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: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023


LIC809 (FAS) - (06/04)
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