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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003931
Report Date: 05/16/2024
Date Signed: 05/16/2024 09:45:23 AM

Document Has Been Signed on 05/16/2024 09:45 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BILBY HOME INC.FACILITY NUMBER:
347003931
ADMINISTRATOR/
DIRECTOR:		ANNE CARILLOFACILITY TYPE:
735
ADDRESS:5411 MARIOLYN WAYTELEPHONE:
(916) 670-6015
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 6DATE:
05/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:42 AM
MET WITH:Ella CarilloTIME VISIT/
INSPECTION COMPLETED:
09:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA met with Designated Administrator Ella Carillo, and explained the purpose of the visit.

LPA Valerio received notification from Alta California Regional Center (ACRC) of a Facility Action Report that was issued to the facility on 05/08/2024. ACRC representatives conducted a visit on 04/24/24. The following deficiencies were observed:
  • Staff did not follow medication instructions for Resident 1: Natural Fiber Powder - On the medication bottle there is an advisory sticker which states "take this product at least 2 hours before or 2 hour after your other medications. The MAR indicated that all morning medications are passed at 7am included the Natural Fiber Powder. The pharmacy was contacted during the review and they confirmed the medication is to be given 2 hours before or after the other medications so it is taken on an empty stomach.
  • Staff did not contact the client's physician prior to administering PRN medications: Resident 2 received acetaminophen on 12/30/23. Resident 3 received Loperamide 2mg on 09/02/23,09/28/23, and 01/08/24. Resident 3 received Olanzapine 5mg on 03/28/23, 04/03/24, 04/10/23, 04/11/24, and 04/17/24. Resident 4 received Lorazepam on 09/23/23.


Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 1, deficiencies are being cited on the attached LIC 809 - D. Appeal Rights were provided. An exit interview was held, and a copy of this report was provided to designated staff Ella.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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 05/16/2024 09:45 AM - It Cannot Be Edited


Created By: Christina Valerio On 05/16/2024 at 08:23 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BILBY HOME INC.
FACILITY NUMBER: 347003931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2024
Section Cited
CCR
80075(b)

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80075 Health Related Services(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:
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Licensee to create a written plan to ensure all medication orders, physician order, and advisory warnings are reviewed and followed. Licensee to submit to LPA by POC due date.
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Based on records review, the licensee did not ensure staff followed medication orders for Resident 1, which poses a potential health, safety, and personal rights risks to residents in care.
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Type B
05/30/2024
Section Cited
CCR80075(b)(6)(A)

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80075 Health Related Services(b) Clients shall be assisted....(6)If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication...(A)Facility staff shall contact the client's physician prior to each dose.. This requirement was not met as evidenced by:
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Licensee to submit a statement of understanding of 80075(b)(6) and provide an in-service training to all staff. Licensee to send in-service sign in sheet to LPA by POC due date.
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Based on records review, the licensee did not ensure 3 out of 6 resident's phyicians were contacted prior to administering a PRN medication. This poses a potential health, safety, and personal rights risk to residents 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 Richardson
LICENSING EVALUATOR NAME:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
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