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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003273
Report Date: 08/30/2021
Date Signed: 08/30/2021 02:17:10 PM

Document Has Been Signed on 08/30/2021 02:17 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:RITA GASPAR CARE HOMEFACILITY NUMBER:
347003273
ADMINISTRATOR:FRENI CHINGFACILITY TYPE:
735
ADDRESS:4309 ROSECREST WAYTELEPHONE:
(916) 857-1222
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 6CENSUS: 6DATE:
08/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Arcee ChingTIME COMPLETED:
02:30 PM
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On 8/30/21 at 1:00pm Licensing Program Analyst (LPA) Kevin Gould arrived at Rita Gaspar Care Home for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Arcee Ching and together conducted a tour of the home.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed the living room without a lamp or overhead lighting.

LPA measured the water temperature, temperature measured at 116 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA did not observed sufficient seven day non-perishable and two day perishable food supplies. Administrator states that food deliveries are conducted every Wednesday. LPA and Administrator discussed need for fresh food and dry goods that are in compliance with regulations. new additional food to be ordered. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 610E Emergency Disaster Plan, Current Administrator Certificate and Client Roster

Per California Code of Regulations, Title 22 the following deficiencies were cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2021
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 08/30/2021 02:17 PM - It Cannot Be Edited


Created By: Kevin Gould On 08/30/2021 at 02:00 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: RITA GASPAR CARE HOME
FACILITY NUMBER: 347003273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(d)
Fixtures, Furniture, Equipment, and Supplies
(d) The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observations during inspection the licensee did not comply with the section cited above as there was no lamp or artificial light source in the living room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2021
Plan of Correction
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Licensee states lamp was broken by resident. Administrator will purchase new lamp and install by POC due date.
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation during inspection, the licensee did not comply with the section cited above in as the food supply observed did not meet two days fresh perishable food supply and the supply of non-perishable staples did not meet a one week supply for the number of residents served which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2021
Plan of Correction
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Administrator will send copies of receipt for food purchased by POC due date and will send photos of food and in fridge and pantry.
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:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2021


LIC809 (FAS) - (06/04)
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