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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003775
Report Date: 11/09/2021
Date Signed: 11/09/2021 12:07:53 PM

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: DATE:
11/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Edna Villanueva TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit. LPA Valerio was met with facility staff Edna Villanueva. LPA was screened for COVID-19 symptoms and temperature taken prior to being allowed entry. Facility staff confirmed residents and staff have not had any signs or symptoms of COVID-19 in the last 10 days.

LPA Valerio toured the facility to ensure compliance with Title 22 regulations. Facility was clean and items were organized. All emergency exits were clear of obstructions. Facility had a 30-day supply of PPE. LPA interacted with residents and staff during the visit. Resident and staff engaged in facility activities and ate lunch during visit.

LPA Valerio reviewed 4 staff files. Staff 3 did not have an updated First Aid/CPR certification on file. Staff 3's First Aid/CPR certification expired 10/2021. Staff 4 did not have a health screening report or TB Test clearance on file.

Based on observations and record review, deficiencies are being cited during today's visit. See LIC 809-D. Appeal rights provided. Failure to correct deficiencies may result in civil penalties. Exit interview held with facility staff, and report was left for Administrator Lionel Nunez.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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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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: LP NUNEZ CARE FACILITY #2
FACILITY NUMBER: 347003775
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2021
Section Cited

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80066 Personnel Records (a)The licensee shall ensure that personnel records...shall contain the following information: (10) A health screening...Tuberculosis test documents as specified in Section 80065(g) This requirement was not met as evidenced by:
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Based on observations, 1 out of 4 staff files did not have a health screening or tuberculosis test on file, which poses a potential health and safety risk to persons in care.
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Type B
12/09/2021
Section Cited

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80075 Health Related Services Staff providing care and supervision shall receive first aid training/CPR... This requirement was not met as evidenced by:
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Based on observatiosn, 1 out of 4 staff files did not have an updated first aid/CPR training on file, which poses a potential health and safet risk to persons 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: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021
LIC809 (FAS) - (06/04)
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