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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004469
Report Date: 04/02/2024
Date Signed: 04/02/2024 05:06:55 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/02/2024 05:06 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:KUNZITE RESIDENTIAL INC.FACILITY NUMBER:
347004469
ADMINISTRATOR:ABRIAM, ZENAIDAFACILITY TYPE:
735
ADDRESS:9646 KUNZITE COURTTELEPHONE:
(916) 897-8801
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
04/02/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Zenaida AbriamTIME COMPLETED:
05:15 PM
NARRATIVE
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On 4/2/24, at 2:36pm, Licensing Program Analyst (LPA) Arvin Villnaueva arrived unannounced to this facility to conduct a case management annual continuation visit to continue the annual visit initiated on 3/18/24. LPA met with one of the staff on duty and explained the purpose of the visit. The facility administrator, Zenaida Abriam, was made aware of the visit and arrived shortly after. Today's visit, there were 4 clients in care with 3 staff on duty.

During this visit, LPA Villanueva conducted an audit of facility files, four (4) client files, and four (4) staff files for regulatory compliance. All four staff have criminal background clearances and are associated to this facility. All client files reviewed contained all required contents including admission agreements, medical assessments, and individual program plan (IPP). All staff files reviewed contained required contents including health screening, TB results, current first aid/CPR, and initial and ongoing required training. LPA completed staff and client 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 monthly fire drills. LPA requested updated copy of LIC 308, LIC 500 surety bond and liability insurance to be emailed to LPA.

During this visit, LPA observed the shed at the backyard to be locked and inaccessible to clients in care.

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 Zenaida Abriam, Administrator, and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
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 04/02/2024 05:06 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 04/02/2024 at 04:18 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: KUNZITE RESIDENTIAL INC.
FACILITY NUMBER: 347004469

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2024
Section Cited
CCR
80076(a)(16)

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80076 Food Services: (a) In facilities providing meals to clients, the following shall apply: (16) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.
This requirement is not met as evidenced by:
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Corrected during this visit: staff immediately removed the cleaning supplies out of the food pantry and locked them in where they store their chemicals.
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Based on observations, the licensee did not comply with the regulation above during physical plant observation, LPA observed cleaning supplies stored inside the food pantry. This poses a potential, health, safety or personal rights risk to persons in care.
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Licensee to submit a written statement of understanding regarding regulation on Food Services. Statement to be submitted to the Department by POC due date.
Type B
04/09/2024
Section Cited
CCR80087(g)

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80087 Buildings and Grounds: (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Licensee to ensure the shed is locked and inaccessible to persons in care at all times.
LPA observed a padlock on the shed.

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Based on observations and interview, the licensee did not comply with the regulation noted above during physical plant observation, LPA observed the backyard shed to be unlocked and observed inside the shed to contain gardening tools which poses a potential health, safety or personal rights risks to persons in care.
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Licensee to submit a written statement of understanding regarding the cited regulation. Statement to be submitted to the Department by POC due date.
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: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024


LIC809 (FAS) - (06/04)
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