347002967-7-27-2023-27-AS-PLEE-CU5PWA-20230727114024

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347002967
Report Date: 07/27/2023
Date Signed: 07/27/2023 11:40:31 AM

Document Has Been Signed on 07/27/2023 11:40 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:	MELINDA'S CARE HOME		FACILITY NUMBER:	347002967
ADMINISTRATOR:	MUNAR, MELINDA		FACILITY TYPE:	740
ADDRESS:	8216 COTTONBALL WAY		TELEPHONE:	(916) 761-1150
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	6	CENSUS: 3	DATE:	07/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Melinda Care Home		TIME COMPLETED:	11:55 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 07/27/2023 at 8:35 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with care staff Maria Seli, who then called licensee/administrator Melinda Munar. Licensee/Administrator arrived approximately 10 minutes later. LPA Lee explained the purpose of the visit. Administrator assisted with today’s visit. Administrator certificate # is 6021667740 and will expire on 11/03/2024. The current census is 3 with three facility staff. LPA Lee toured the facility with administrator, Melinda at 10:40 AM. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident 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 six (6) non-ambulatory residents and approved for 3 hospice residents . 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-way perishable food supplies. Hot water temperature was measured at 109.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguisher and smoke detector are in good repair. Fire extinguisher was last serviced on 03/10/2023. LPA Lee observed carbon monoxide detector not in good repair. Licensee replaced the carbon monoxide with new batteries and LPA Lee observed the carbon monoxide working. LPA Lee observed the facility has a has a public telephone in the kitchen and the facility have the required posters posted. The facility has infection control plan and has an emergency disaster plan. Facility thermostat observed at 78 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed 3 out of 3 medication administration record (MAR) and it was complete. First aid kit was checked and is complete. LPA Lee requested client and staff files for review. LPA Lee reviewed 3 out of 3 client files and they all were complete. LPA Lee reviewed 3 out of 3 staff files and they were complete. LPA Lee reviewed staff criminal record clearances and 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. Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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: MELINDA'S CARE HOME	FACILITY NUMBER: 347002967
	VISIT DATE: 07/27/2023

NARRATIVE

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The following documents will be email to LPA Lee by 08/03/2023 by 5:00 PM by end of day.
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 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 deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these 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: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 07/27/2023 11:40 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: MELINDA'S CARE HOME	FACILITY NUMBER: 347002967
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. The licensee did not ensure that the carbon monoxide detector was in working condition, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/27/2023
	Plan of Correction
1 2 3 4	Licensee changed the batteries in the carbon monoxide dectors and carbon was tested again and LPA Lee observed carbon in working condition.

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: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

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