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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002401
Report Date: 08/03/2023
Date Signed: 08/03/2023 10:49:57 AM

Document Has Been Signed on 08/03/2023 10:49 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ED DAVID CARE HOMES INC. #4FACILITY NUMBER:
347002401
ADMINISTRATOR:MARINA DAVIDFACILITY TYPE:
735
ADDRESS:7505 AUSPICIOUS WAYTELEPHONE:
(916) 349-8285
CITY:SACRAMENTOSTATE: CAZIP CODE:
95842
CAPACITY: 6CENSUS: 6DATE:
08/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator, Marta BlancoTIME COMPLETED:
10:50 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 07/24/23 and on 07/30/23. LPA met with Administrator Marta Blanco and explained the reason for the visit.

Alta California Regional Center Special Incident Report submitted by facility on 07/25/23 and on 08/01/23 to CCL stated that Staff (S1) did not give 1 scheduled medication Simvastatin -20mg (1 tablet) to R1 on the evening of 07/24/23 and R2 did not get their scheduled medications on 07/30/23 as R2s medications ( morning medication missed: Buspirone HCL 7.5mg, Ferrous Sulfate- 325mg, Baclofin- 10mg, Loratadine- 10mg, Vitamin B12- 2500mcg, Vitamin D -1000, Calcium- 600mg, Omeprazole- 40mg, Evening dose missed: Baclofen- 10mg, Buspirone HCL -15mg, Calcium- 600mg, Bedtime dose missed: Aripirazole- 10mg, Simvastatin- 20mg. ) were not refilled by pharmacy and facility did not make sure that R2 have their medications filled in timely manner. Facility management found out on 07/30/23 that R2 did not have their medications refilled. Record review indicated that R2’s medication had zero refills therefore additional refills needed to be approved by R2’s physician, which resulted in a delay in R2 obtaining medication timely. Facility did not ensure that R2 have medications refills ordered by R2s physician in timely way which resulted R2 missed their medications on 07/30/23.

Facility notified R1s and R2s physician, CCL, ALTA and other agencies regarding these medication errors. Per facility’s reports, there were no changes to R1s and R2s health due to this medication error and R1 and R2s were at their baseline. Based on this information, it was determined that the facility did not administer these medications to R1 and R2 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: 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)
Page: 1 of 2
Document Has Been Signed on 08/03/2023 10:49 AM - It Cannot Be Edited


Created By: Talwinder Bains On 08/03/2023 at 07:58 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 HOMES INC. #4
FACILITY NUMBER: 347002401

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, it has been concluded that facility did not give medications to R1 on 07/24/23 and to R2 on 07/30/23 as ordered by residents (R1,R2) 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.

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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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