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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003869
Report Date: 12/15/2021
Date Signed: 12/15/2021 11:41:40 AM

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:TATE FAMILY CARE #2FACILITY NUMBER:
347003869
ADMINISTRATOR:TATE, CHERESEFACILITY TYPE:
735
ADDRESS:8517 AVERY CTTELEPHONE:
(916) 627-1992
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:4CENSUS: DATE:
12/15/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Cherese TateTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Anthony Tuck, LPM Czarrina Camilon-Lee, Alta Regional Service Coordinator's Rowena Lopez and Olivia Procida were joined by Licensee Cherese Tate for a virtual meeting due to COVID-19 pre-cautionary measures. LPA discussed the purpose of the meeting and the elements of the case management with Facility Licensee Cheres Tate.

LPA discussed the concerns based on observations that were found during the virtual technical assistance visit with Licensee held on 12/14/2021. LPA discussed concerns with staff not wearing an N95 mask in the facility while the care home has an active COVID+ resident. LPA discussed the concerns of the facility not following the guidelines of the Mitigation plan submitted to Community Care Licensing Division (CCLD). LPA asked the Licensee if she spoke with staff regarding wearing an incorrect mask while tending to a COVID+ resident. Licensee stated she did not ask staff why an incorrect mask was being worn as observed during the virtual visit held on 12/14/2021. LPA provided Licensee with online training video links for donning/doffing ppe, seal check, Goal of Infection Control, How Does COVID- 19 Spread, Disinfection What’s the Difference, and What is N95? for training refresher to administer to all facility staff. LPA advised Licensee to schedule N95 FIT tests for all staff per CAL OSHA requirement.

There were deficiencies found during the case management virtual call. Deficiencies are cited from California Code of regulations, Title 22 and citations are listed on the attached LIC809D.

An exit interview was conducted with Cherese Tate via Microsoft Teams virtual call, and a copy of this report was provided to Cherese Tate via email, and an electronic email read receipt confirms receiving these documents. Licensee is to send a signed copy to LPA Anthony.Tuck@dss.ca.gov by COB 12/15/21.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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: TATE FAMILY CARE #2
FACILITY NUMBER: 347003869
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2021
Section Cited

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80061 Reporting Requirements
(a) Each licensee... shall furnish to the licensing agency reports as required by the Department, including, but not limited to (1) Events reported shall include the following: (H) Epidemic outbreaks. This requirement was not met as evidenced by:
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Based on interviews and observations during a virtual visit with the facility staff, and DSS Nurse conducted on 12/14/2021. Facility was observed not following the mitigatin plan with COVID+ resident in isolation room. Staff was not wearing an N95 mask in the facility. This poses a potential health and safety risk to persons in care.
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Complete N95 FIT Test for all facility staff.
Review PIN 21-32.1 ASC for Staff testing and Masking Guidance. Licensee will submit copy of training log for all staff to LPA by POC due date.

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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2021
LIC809 (FAS) - (06/04)
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