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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003819
Report Date: 06/02/2023
Date Signed: 06/02/2023 04:53:50 PM

Document Has Been Signed on 06/02/2023 04:53 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 AC/SC, 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: 6DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Napoleon MuchaTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with administrator Napoleon Mucha and explained the purpose of the visit.

Mucha's administrator certificate number is 6022833735 and it expires on 12/22/24.

LPA Moleski reviewed three staff files (S1-S3) and three resident files (R1-R3).

LPA Moleski toured the facility with Mucha and inspected common areas, the kitchen, resident bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 75 degrees Fahrenheit, which is within the required range of 68 and 85 degrees.

LPA Moleski and Mucha observed an initial measurement of a bathroom water faucet reading 145 degrees Fahrenheit, which is outside the required range of 105 and 120 degrees.

LPA Moleski observed a first aid kit, and working carbon monoxide/smoke detectors. LPA Moleski observed the required minimum 2-day perishable supply of food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed a locked cabinet for the storage of cleaning solutions and knives.

LPA Moleski and Mucha observed a fire extinguisher which had last received annual service in April 2022.

[continued on 809-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
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 06/02/2023 04:53 PM - It Cannot Be Edited


Created By: Vincent Moleski On 06/02/2023 at 04:01 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: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of a temperature measurement, the licensee did not ensure water temperatures remained below 120 degrees, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2023
Plan of Correction
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Licensee lowered the temperature same-day, LPA took a reading and it measured 115 degrees. This POC will be cleared.
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of a fire extinguisher, the licensee did not ensure the fire extinguisher was serviced annually, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2023
Plan of Correction
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Licensee agrees to purchase a new fire extinguisher and send a photo of the receipt to LPA Moleski.
vincent.moleski@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:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023


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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ST. PHILOMENA HOMECARE II, LLC.
FACILITY NUMBER: 347003819
VISIT DATE: 06/02/2023
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LPA Moleski interviewed two staff members (S1-S2) and two residents (R4-R5).

This facility is being cited per 22 CCR Sections 80020(a) and 80088(e)(1). An exit interview was held with Mucha. Appeal rights and a copy of this report was left with Mucha.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
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