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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003936
Report Date: 06/24/2022
Date Signed: 07/14/2022 09:35:47 AM

Document Has Been Signed on 07/14/2022 09:35 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
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: 5DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Valentina MarinovaTIME COMPLETED:
12:00 PM
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This is an amended report to remove reference to a pool in the back yard as there is no pool at this facility and the reference to a pool was written in error.

On 6/24/22 at 9:15am Licensing Program Analyst (LPA) Kevin Gould arrived at Tender Home Senior care for the purpose of conducting a required 1 year annual inspection. LPA met with Licensee, Valentina Marinova and together conducted a tour of the home.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. Facility has an updated infection control plan and will send to LPA prior to 6/30/22

LPA measured the water temperature, temperature measured at 113 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

LPA conducted file review for all residents and observed all residents with dementia did not and an updated physicians report conducted within the last 12 months and did not have updated needs and services updates regarding dementia care within the last 12 months.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report and Client Roster. Per California Code of Regulations, Title 22 the following deficiencies were cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2022
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 06/24/2022 11:37 AM - It Cannot Be Edited


Created By: Kevin Gould On 06/24/2022 at 11:27 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
, 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: 06/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of 5 residednt records, the licensee did not comply with the section cited above in 3 out of 5 resident records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2022
Plan of Correction
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Facility will contact all responsible parties for residents with a diagnosis of dementia and provide them with the LIC 602(a) to be completed by the resident's physician by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022


LIC809 (FAS) - (06/04)
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