347001904-3-14-2023-27-AS-PLEE-CPWQ3R-20230314114911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347001904
Report Date: 03/14/2023
Date Signed: 03/14/2023 11:49:23 AM

Document Has Been Signed on 03/14/2023 11:49 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	LP NUNEZ CARE FACILITY		FACILITY NUMBER:	347001904
ADMINISTRATOR:	BRIAN A. JOHNSON		FACILITY TYPE:	740
ADDRESS:	8000 35TH AVENUE		TELEPHONE:	(916) 386-8332
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95824
CAPACITY:	4	CENSUS: 4	DATE:	03/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Ferdinand Sadaya		TIME COMPLETED:	12:00 PM

NARRATIVE

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On 03/14/2023 at 8:25 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with care staff Ferdinand Sadaya and explained the purpose of the visit. Care staff Ferdinand called administrator Lionel Nunez and administrator instructed care staff Ferdinand to assist with today’s visit. Administrator certificate # is 60002516735 and will expired on 11/17/2023.

The facility has one main Covid-19 screening entry point. The facility has Covid-19 posting throughout the facility. The furniture is spaced six feet apart, and the facility does daily cleaning. The facility has a 30-day supply of PPE. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve four (4) residents of which (1) may be non-ambulatory. The facility is also approved for hospice waiver for (1) client. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Lee observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 119.0 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 03/11/2022 which is not up to date. Facility thermostat observed at 70 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to clients. First aid kit was checked and is complete. LPA Lee requested client and staff files for review. LPA Lee reviewed (2) client files and (3) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA Lee verified staff training for staff file reviews.
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SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LP NUNEZ CARE FACILITY	FACILITY NUMBER: 347001904
	VISIT DATE: 03/14/2023

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The following documents shall be submitted to LPA Lee by 03/21/2023 by close of business 5:00PM.
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted, and a copy of the LIC 809 reports, LIC 809-D Page, and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/14/2023 11:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LP NUNEZ CARE FACILITY	FACILITY NUMBER: 347001904
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review the lincesee did not ensure fire extinguisher is up to date. Fire extinguisher was last service on 03/11/2022. This posed an immediate health and safety risk to residents in care.
	POC Due Date: 03/15/2023
	Plan of Correction
1 2 3 4	Licensee stated fire marshal will be contacted to inspect and renew all fire extinguishers. Licensee agrees to email LPA Lee pictures of new fire extinguisher serice date by POC date 03/15/2023 by close of business 5:00 PM.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC809 (FAS) - (06/04)

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