347004228-7-26-2023-59-AS-TBAS-CU4NS4-20230726104232

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347004228
Report Date: 07/26/2023
Date Signed: 07/26/2023 10:42:43 AM

Document Has Been Signed on 07/26/2023 10:42 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	FOUR SEASONS CARE HOME		FACILITY NUMBER:	347004228
ADMINISTRATOR:	IOAN NAGY		FACILITY TYPE:	740
ADDRESS:	8322 CENTRAL AVENUE		TELEPHONE:	(916) 910-9419
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	6	CENSUS: 3	DATE:	07/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator, Ioan Nagy		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Talwinder Bains arrived on 07/26/23 to conduct the annual inspection. LPA met with administrator, Ioan Nagy and explained the purpose of the visit. LPA was told by Ioan that facility has 3 residents in care as of today. LPA observed 2 residents present in common area and 1 resident was in their room during today's visit. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed residents files for R1 and R2 and staff files for S1 and S2. R1 and S1 files contained the required paperwork. LPA observed that health screening (LIC503),TB test, required annual training ,LIC501,LIC9052 were missing in S2 file. Furthermore, it has also been observed that R2 file missing pre-admission appraisal as required per Title 22. LPA and Ioan toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use. LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 08/05/23. Deficiencies are cited on LIC809D per Title 22. Exit interview conducted. Appeal Rights and copy of this report left at facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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 07/26/2023 10:42 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FOUR SEASONS CARE HOME	FACILITY NUMBER: 347004228
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(b)

Personnel Records

(b) Personnel records shall be maintained for all volunteers and shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	During file review, LPA observed that S2 file missing LIC501,LIC503,TB test ,LIC9052 as required which poses a potential health risks to residents in care.
	POC Due Date: 08/15/2023
	Plan of Correction
1 2 3 4	Licensee shall complete all required documents for S2 file per this regulation and send a copy to CCL by POC date-08/15/23.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	During file review, LPA observed that S2 file missing annual training as required which poses a potential health risks to residents in care.
	POC Due Date: 08/15/2023
	Plan of Correction
1 2 3 4	Licensee shall complete all required annual training for S2 file per this regulation and send a copy to CCL by POC date-08/15/23.

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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/26/2023 10:42 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FOUR SEASONS CARE HOME	FACILITY NUMBER: 347004228
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.696(a)

Other Provisions

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	During file review, LPA observed that S2 file missing training for above section(s) as required which poses a potential health risks to residents in care.
	POC Due Date: 08/15/2023
	Plan of Correction
1 2 3 4	Licensee shall complete all required training for S2 file per this regulation/section and send a copy to CCL by POC date-08/15/23.

Type B

Section Cited

CCR

87464(d)

Basic Services

(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	During file review for R2, LPA observed that R2 file missing pre-admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2023
	Plan of Correction
1 2 3 4	Licensee shall complete pre-admission appraisal for R2 file per this regulation/section and send a copy to CCL by POC date-08/15/23.

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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

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