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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003819
Report Date: 04/21/2022
Date Signed: 04/21/2022 03:07:06 PM

Document Has Been Signed on 04/21/2022 03:07 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:ST. PHILOMENA HOMECARE II, LLC.FACILITY NUMBER:
347003819
ADMINISTRATOR:MUCHA, NAPOLEONFACILITY TYPE:
735
ADDRESS:8712 STATUE WAYTELEPHONE:
(916) 684-9330
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 5DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Pepito Severo - AdministratorTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced 1 Year Required Annual Inspection Visit. LPA met with Administrator and explained purpose of visit. Administrator Certificate expires 01/15/2024 . During today's visit, 4 clients were home, and 1 client was a day program. This facility operates as a level 3 home vendorized by Alta California Regional Center.

LPA inspected physical plant with Administrator. The interior and the exterior of the facility were inspected including the common living spaces, resident bedrooms and bathrooms, and kitchen. Bathrooms and bedrooms were clean and in good repair. There is a locked storage for medications and toxins. Food supply was adequate for 2-day perishable and 7-day nonperishable items. Fire Extinguisher expires 04/23/2022. Smoke alarms were checked and in found in good working order. Fire drills are conducted as required. Carbon Monoxide detector was found in good working order. LPA observed the facility at a comfortable temperature. LPA observed a sufficient amount of towels and linens. This facility is operating within the scope of their license.

LPA reviewed (5) resident and (4) staff records. Resident files and P&I records were not found to be complete and current. Resident #1 was missing admissions agreement. Resident #1, #3, and #5 were missing initial needs and service plans. Resident P&I monies and documentation were found to be accurate. A 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.

LAP requested the following documents to be submitted to Community Care Licensing (CCL) by April 28th: 2022 via email: ruth.wallace@dss.ca.gov
LIC 308 Designation of Administrative Responsibility, LIC 309 - Administrative Organization, LIC 500 Personnel Report, LIC 610D the Emergency Disaster Plan, and Administrator’s Certificate
The following deficiencies are cited pursuant to California Code of Regulations, Title 22, Chapter 6, Section 85072. Deficiencies are listed on the attached LIC 8099-D's

Exit interview conducted with administrator. A copy of reports and appeal rights were given to administrator.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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 04/21/2022 03:07 PM - It Cannot Be Edited


Created By: Ruth Wallace On 04/21/2022 at 02:56 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: ST. PHILOMENA HOMECARE II, LLC.
FACILITY NUMBER: 347003819

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)(1)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any. (1) Prior to admitting a developmentally disabled adult recommended by a Regional Center, the licensee of an ARF shall obtain from the Regional Center written certification which states that there was no objection to the placement by any persons specified in Welfare and Institutions Code Section 4803.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in resident #1 was missing original admission agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2022
Plan of Correction
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Licensee agrees to submit via email to LPA an admission agreement for resident #1 by Plan of Correction Date (POC) 4/28/2022. ruth.wallace@dss.ca.gov
Type B
Section Cited
CCR
85068.2(b)(1)(G)1
Needs and Services Plan
1. The licensee shall document the initial assessment based on information available at the time of the assessment. This information shall be maintained and brought current thereafter as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in resident #1, #3, and #5 were missing appraisal needs/service plans which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2022
Plan of Correction
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Licensee agrees to submit via email to LPA appraisal needs/service plans for resident #1, #3, and #5 by Plan of Correction Date (POC) 4/28/2022. ruth.wallace@dss.ca.gov
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: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022


LIC809 (FAS) - (06/04)
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