347003426-1-19-2024-27-AS-PLEE-CZMRJN-20240119120413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003426
Report Date: 01/19/2024
Date Signed: 01/19/2024 12:04:20 PM

Document Has Been Signed on 01/19/2024 12:04 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	DEL VISTA RESIDENTIAL CARE		FACILITY NUMBER:	347003426
ADMINISTRATOR:	SAEL, TATY L.T.		FACILITY TYPE:	740
ADDRESS:	78 DEL VISTA CIRCLE		TELEPHONE:	(916) 690-7243
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	6	CENSUS: 5	DATE:	01/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:21 AM
MET WITH:	Taty Sael		TIME COMPLETED:	12:10 PM

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 01/19/2024 at 8:21 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met administrator Taty Sael who assisted with today’s visit. LPA Lee explained the purpose of the visit. Administrator certificate # is 6002575740 and will expire on 06/02/2025. The current census is 5 with 2 facility staff. This facility is a single story building licensed to serve six (6) non-ambulatory residents and approved for hospice waiver for three residents in care. LPA 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. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient two-day perishable and seven-day non-perishable food supplies. LPA Lee observed sharp knives kept locked. Hot water temperature was measured at 117.5 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in entry way and was last serviced on 12/19/2023. The last fire drill was conducted on 12/29/2023. LPA observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. Facility thermostat observed at 70 degrees Fahrenheit. LPA Lee observed toxins made accessible to residents in care. LPA Lee observed nail polish remover and Vicks VapoRub in the linen closet. Furthermore, LPA Lee observed laundry detergent, plant food, fabric softener, and fabric odor eliminator in the garage made accessible to residents in care. During today’s visit LPA Lee observed administrator removed all toxins that was made accessible to resident and locked them in a locked cabinet. Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

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 01/19/2024 12:04 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DEL VISTA RESIDENTIAL CARE	FACILITY NUMBER: 347003426
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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. Licensee did not ensure that cleaning solutions and toxins are made inaccessible to residents in care which poses/posed a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 01/19/2024
	Plan of Correction
1 2 3 4	nbnbnnbbbisit, LPA Lee observed licensee removed the cleaning supplies, nail polish remover and Vicks and placed then in a locked-up cabinet.

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) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DEL VISTA RESIDENTIAL CARE	FACILITY NUMBER: 347003426
	VISIT DATE: 01/19/2024

NARRATIVE

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LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed and compared 3 out of 5 residents LIC 622 Centrally Stored Medication and Destruction Record with residents medications and is was complete and accurate. The first aid kit was checked and contained all the required components. LPA requested residents and staff files for review. LPA reviewed 5 out of 5 resident files and 3 staff files and they were all 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.

The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by 01/26/2025 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) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC809 (FAS) - (06/04)

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