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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002248
Report Date: 07/27/2022
Date Signed: 07/28/2022 02:49:46 PM

Document Has Been Signed on 07/28/2022 02:49 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:RODNEY KEINATH COUNTRY HOMEFACILITY NUMBER:
347002248
ADMINISTRATOR:KEINATH, RODNEYFACILITY TYPE:
735
ADDRESS:8267 CHESTER DRIVETELEPHONE:
(916) 682-9485
CITY:SACRAMENTOSTATE: CAZIP CODE:
95830
CAPACITY: 6CENSUS: 6DATE:
07/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Ester Olivia MaramisTIME COMPLETED:
03:12 PM
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Licensing Program Analysts (LPAs) Avelina Martinez and Arielle Pascua arrived at this facility unannounced on 07/28/2022 at 2:30 PM to conduct a case management visit. LPA met with Ester Olivia Maramis and explained the purpose of the visit.

The purpose of the case management visit is to follow up on a learned deficiency during a complaint investigation 27-AS-20220712125821.

Based on record review, it was learned the facility was not ensuring to maintain medication Administration Records (MAR) for resident 1 and resident 2. Facility staff were not correctly updating MAR sheet to reflect discontinued medication and did not create new MAR medication entries that reflect current medication orders.

The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code.


An exit interview was conducted. A copy of this 809 report, 809-D report, and appeals rights were given to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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 07/28/2022 02:49 PM - It Cannot Be Edited


Created By: Avelina Martinez On 07/27/2022 at 04:35 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: RODNEY KEINATH COUNTRY HOME
FACILITY NUMBER: 347002248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/10/2022
Section Cited
CCR
80075(7)(C)

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80075(7)(C) Health Related Services: The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications...The drug name, strength and quantity. This requirement was not met as evidence by:
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Facility staff agreed to provide medication management training for all staff by POC Date 08/10/2022. Facility will email LPA training documents by POC date 08/10/2022.
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Based on observation and record
review, the Licensee did not ensure R1 and R2 MAR sheets reflected current medication orders and did not correctly document discontinued orders on MAR sheets. This posed a potential 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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
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