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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004245
Report Date: 05/14/2024
Date Signed: 05/14/2024 01:00:03 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/14/2024 01:00 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MAINLINE HOME CAREFACILITY NUMBER:
347004245
ADMINISTRATOR/
DIRECTOR:		MARRI EDQUIDFACILITY TYPE:
740
ADDRESS:9445 MAINLINE DRIVETELEPHONE:
(916) 690-8932
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
05/14/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Aida Gatchalian and Maria Magnolia TolonTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 5/14/24, at 9:35am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct an annual continuation visit. The purpose of this visit is to continue the required annual inspection initiated on 4/22/24. LPA initially met with one of the staff on duty and explained the purpose of the visit. The administrator, Maria Magnolia Tolon, was notified of the visit and arrived shortly after along with the licensee, Aida Gatchlian. Present during this visit were 4 residents in care with 2 staff on duty.
Note that prior to this visit, a fire inspection was initiated to obtain a fire clearance for the room marked as "staff room" on the facility sketch as resident bedroom. This room is not fire cleared for resident use at this time. Per interview with administrator and licensee, the fire marshal visited on 4/23/24 and suggested to install a ramp for the exit door of this room and will revisit the facility once the Department submit form STD 850 and the installation of the ramp has been completed. LPA Villanueva submitted the form on 5/3/24 to the Consumnes CSD Fire Department. Per today's observation, a fire door has been installed in this bedroom.

During this inspection, LPA conducted an audit of facility files, 5 resident files, and 3 staff files for regulatory compliance. All staff files reviewed contained required contents including health screening, TB results, current first aid/CPR, and initial and ongoing required training and are associated to this facility. 5 of 5 resident files reviewed contain updated Physician Report and Needs and Services Plan. Additionally, resident files contain at least the following: Admission Agreement, Centrally Stored Medication Records, Weight Records, Emergency Information, and Consent Forms. LPA discovered 1 of 5 residents' medical assessment was signed by a Nurse Practitioner (NP). A technical advisory was provided to obtain a waiver request from the Department. LPA also reviewed resident medications for regulatory compliance. No issues were noted at this time. LPA conducted staff and resident interviews.

Facility’s liability insurance is current per regulatory requirements. LPA reviewed facility’s disaster plan to ensure regulatory compliance. LPA observed that facility conducts quarterly fire drills. Last drill conducted was on 4/5/24. LPA was provided current copy of facility's LIC 308, LIC 500, and liability insurance.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.



An exit interview was conducted with Aida Gatchalian and Maria Magnolia Tolon, and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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 05/14/2024 01:00 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 05/14/2024 at 12:11 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MAINLINE HOME CARE
FACILITY NUMBER: 347004245

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2024
Section Cited
CCR
87202(a)(1)

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(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal... (1) Nonambulatory persons.

This requirement is not met as evidenced by:
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LPA submitted form STD 850 to the local fire department on 5/3/24.
Local fire marshal conducted an initial visit and suggested for an installation of a ramp at the exit door.
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Based on observation and interview, the licensee did not comply with the regulation noted above. It was discovered that the room fire cleared as "staff" room on the facility sketch is being used as a resident room by non-ambulatory resident during this visit. This poses an immediate health and safety risk to residents in care.
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Licensee to install a ramp at the exit door of the said bedroom and will send photo evidence to the Department once completed.
Licensee to submit a written statement of understanding of the regulation CCR 87202 to the Department by POC due date.

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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:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
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