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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003936
Report Date: 05/04/2022
Date Signed: 05/04/2022 03:59:14 PM

Document Has Been Signed on 05/04/2022 03:59 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:TENDER HOME SENIOR CAREFACILITY NUMBER:
347003936
ADMINISTRATOR:MARINOVA, VALENTINAFACILITY TYPE:
740
ADDRESS:3499 PONZI COURTTELEPHONE:
(916) 851-1888
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 6CENSUS: 6DATE:
05/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Valentina MarinovaTIME COMPLETED:
04:15 PM
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On 5/4/22 at 1:30pm Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management inspection to address deficiencies observed while at the facility for an unrelated complaint investigation.

LPA arrived at the facility and looked into the facility from the front window. LPA observed Staff member not wearing a mask and quickly dawn a mask when she opened the door and observed LPA was at the door. When LPA entered the facility LPA observed three visitors in the living room visiting with a resident. All were not wearing masks. LPA informed Administrator of LPAs observations and administrator provided masks to the visitors who all dawned them without comment or complaint. .

Additionally, LPA conducted file review of the program statement and plan of operation for the facility at the program office. LPA observed the plan of operation to state: "All medications will be self administered, recorded and given per physician's orders". During a previous inspection LPA attempted to review medication logs and was informed by Licensee that the facility was not documenting medication administration. Licensee has resumed medication documentation per the plan of operation.

The following deficiencies are cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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 05/04/2022 03:59 PM - It Cannot Be Edited


Created By: Kevin Gould On 05/04/2022 at 03:06 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: TENDER HOME SENIOR CARE
FACILITY NUMBER: 347003936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2022
Section Cited
CCR
87468.1(a)(2)

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Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by, on 5/4/22 licensee did not ensure the personal rights of persons in care to safe and healthful accommodations and engaged in conduct inimical to the
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Licensee will submit daily attestations to department indicating the Administrator has been at the facility and has observed all staff and visitors wearing face coverings as required. If a staff or visitor is observed without a mask Licensee will submit what steps and discipline was enacted to correct the staff or visitors.
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health, welfare, and safety of persons in care, in that facility staff Tamaka Holder and three visitors did not wear face coverings while in the facility, as required by the Order of the State Public Health Officer dated June 11, 2021 requiring compliance with CDPH Guidance for the Use of Face Coverings, and as required by COVID-19 Prevention Emergency Temporary Standards (ETS) at Title 8, CCR section 3205, and an individual mask exemption did not apply.
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Type A
05/05/2022
Section Cited
CCR87208(a)

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Plan of Operation: (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the
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Facility will continue to document all prescribed medications and PRNs administered to residents. Licensee will email LPA with updated MARs for each resident weekly (Mondays) to verify that medications are being documented and recorded by staff. If it is noted a medication was given and not recorded, an incident
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services to residents shall be submitted to the licensing agency for approval. This requirement was not met as evidenced by LPA review of facility plan of operation which included language that all medications administered would be recorded and documented. LPA observed the facility had not been following the plan of operation and recently reinstituted documenting medication administration.
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report will be sent to the department.
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-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022


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Document Has Been Signed on 05/04/2022 03:59 PM - It Cannot Be Edited


Created By: Kevin Gould On 05/04/2022 at 03:27 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: TENDER HOME SENIOR CARE
FACILITY NUMBER: 347003936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2022
Section Cited
CCR
87405(d)(2)

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Administrator - Qualifications and Duties: The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply: (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This
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Licensee will submit daily attestations to department indicating the Administrator has been at the facility and has observed all staff and visitors wearing face coverings as required. If a staff or visitor is observed without a mask Licensee will submit what steps and discipline was enacted to correct the staff or visitors.
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requirement was not met as evidenced by LPAs observations that staff continue to not wear masks when inside the facility as required by the Order of the State Public Health Officer dated June 11, 2021 requiring compliance with CDPH Guidance for the Use of Face Coverings, and as required by COVID-19 Prevention Emergency Temporary Standards (ETS) at Title 8, CCR section 3205, and an individual mask
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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-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022


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