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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003775
Report Date: 08/05/2022
Date Signed: 08/10/2022 02:16:32 PM

Document Has Been Signed on 08/10/2022 02:16 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:LP NUNEZ CARE FACILITY #2FACILITY NUMBER:
347003775
ADMINISTRATOR:NUNEZ, LIONELFACILITY TYPE:
735
ADDRESS:9374 LOS TORRES DRTELEPHONE:
(916) 685-7759
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 4DATE:
08/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:EDNA VILLANUEVA - Assistant AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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 Licensing Program Analysts (LPA's) Ruth Wallace and Kesha Lewis conducted a unannounced Required 1 Year Annual Inspection Visit. LPA's met with Assistant Administrator and explained purpose of visit. Administrator Certificate Expires 11/17/2023. During today's visit, three residents present at facility and one resident is at Day Program. This facility operates as a level 4D home vendorized by Alta California Regional Center.

LPA's and assistant administrator toured the interior and the exterior of the facility. LPA's inspected the common living spaces, resident bedrooms and bathrooms, and kitchen. Bathrooms and bedrooms were clean and in good repair. Medications and toxins were in a locked storage area. Food supply is adequate for 2 day perishable and 7 day nonperishable. Smoke alarms were checked and in found in good working order. Fire extinguishers were serviced 5/5/2022 and are current. Fire drills are conducted as required. Carbon Monoxide detector was found in good working order. LPA's observed a sufficient amount of towels and linens. This facility is operating within the scope of their license. LPA's reviewed two ( resident and four (4) staff records. Resident files and P&I records were found to be complete and current. Resident P&I monies and documentation were found to be accounted for. R4 was missing a restricted health care plan. review of staff records indicates that all facility staff have received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates. Facility is conducted staff training as required.

The administrator will submit updated copies via email to LPA Wallace by 8/12/22: LIC 308 Designation of Administrative Responsibility, LIC 400 - Affidavit Regarding Client Cash Resources, Surety Bond, and LIC 610D the Emergency Disaster Plan

Based on observations and record review, one deficiency is being cited during today's visit. Per California Code Regulations, Title 22. See LIC 809-D. Failure to correct deficiencies may result in civil penalties.
Exit interview conducted with Assistant Administrator. Copies of reports and appeal rights were left at conclusion of visit.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
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 08/10/2022 02:16 PM - It Cannot Be Edited


Created By: Ruth Wallace On 08/05/2022 at 02:32 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: LP NUNEZ CARE FACILITY #2
FACILITY NUMBER: 347003775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80092.2(a)
Restricted Health Condition Care Plan
(a) If the licensee of an ARF chooses to care for a client with a restricted health condition, as specified in Section 80092, the licensee shall develop and maintain, as part of the Needs and Services Plan, a written Restricted Health Condition Care Plan. The plan must include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in Resident (4) did not have a restricted health care plan for Community Care Licensing (CCL) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2022
Plan of Correction
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Licensee will submit a restricted health care plan for R4 to CCL by POC Date of 8/12/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022


LIC809 (FAS) - (06/04)
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