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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003507
Report Date: 03/29/2022
Date Signed: 03/29/2022 02:35:01 PM


Document Has Been Signed on 03/29/2022 02:35 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:VICIO CARE HOMEFACILITY NUMBER:
347003507
ADMINISTRATOR:VICIO, LEA M.FACILITY TYPE:
740
ADDRESS:9063 WHARTON WAYTELEPHONE:
(916) 689-8012
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
03/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Lea VicioTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit. LPA Valerio explained the purpose of the visit and was met by

On 03/16/2022, Alta Regional Center Service Coordinator Jazmine Kung-Gunion informed LPA Valerio the facility was placed on sanctions effective 3/16/2022 due to medication errors. Due to this finding, the facility is not within compliance of Title 22 regulations and deficiencies are being cited.

LPA Valerio reviewed current residents Medication Administration Records for 03/01/22 to 03/29/22 AM. LPA observed all resident's MAR to be completed with a signature by facility staff. No concerns for medication errors noted or observed on this visit.

LPA Valerio observed staff interacting with residents in a positive and respectful manner. Staff were observed to be conducting activities, cleaning, and assisting residents.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed today and cited on the attached LIC 809-D.  Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was provided to Administrator.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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 03/29/2022 02:35 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: VICIO CARE HOME
FACILITY NUMBER: 347003507

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2022
Section Cited

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87465 Incidental Medical and Dental Care (c)..., facility staff designated by the licensee shall be permitted to assist the resident with self-administration... (3)A record of each dose is maintained in the resident's record. The record shall include the date and time...This requirement was not met as evidenced by:
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Based on record review, 6 out of 6 residents did not have staff initials for medications on the evening of 03/08/22 and the morning of 03/09/22, which poses a potential health 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
LIC809 (FAS) - (06/04)
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