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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003949
Report Date: 08/10/2023
Date Signed: 08/10/2023 11:04:08 AM


Document Has Been Signed on 08/10/2023 11:04 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:HOLY FAMILY HOMEFACILITY NUMBER:
347003949
ADMINISTRATOR:JACKSON, CRISINAFACILITY TYPE:
740
ADDRESS:1440 HOOD ROADTELEPHONE:
(916) 532-7078
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:6CENSUS: 6DATE:
08/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Gloria DulayTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on August 10, 2023 at 10:15 AM. LPA Martinez met with Gloria Dulay and explained the purpose of the visit.

The purpose of the visit today, is in response to a learned deficiency during complaint investigation 27-AS-20230804152452. As of August 04, 2023, staff administered R1 Escitalopram 5MG take 1 tablet by mouth daily for 14 days then stop. However, R1's Medication Administration Record (MAR) states, "Take 2 tablets by mouth at bed time". The facility did not update R1's MAR to reflect Escitalopram medication change. As a result, the facility did not maintain R1' medication record.

The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code.


An exit interview was conducted, and a 809 report, 809-D page, and appeal rights were given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
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 08/10/2023 11:04 AM - It Cannot Be Edited

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: HOLY FAMILY HOME
FACILITY NUMBER: 347003949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2023
Section Cited
CCR
87465(h)(6)

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87465(h)(6) Incidental Medical and Dental Care: The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained...This requirement was not met as evidence by:
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Facility staff has created a new MAR for Escitalopram new order. Facility staff agrees to conduct Incidental and medical and Dental training for all staff by POC date 08/23/2023. Training documents will be emailed to LPA Martinez on by POC Date 08/23/2023 by 5 PM.
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Based record review, the Licensee did not ensure R1's medication record was updated to reflect Escitalopram new medication order. This posed a potential health and safety risk to R1
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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: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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