<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004519
Report Date: 02/23/2022
Date Signed: 02/23/2022 04:35:47 PM

Document Has Been Signed on 02/23/2022 04:35 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PEER HOME #1FACILITY NUMBER:
347004519
ADMINISTRATOR:CUPINO, RAULFACILITY TYPE:
735
ADDRESS:9560 CASTLECAVE WAYTELEPHONE:
(916) 585-9103
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
02/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Monica ButayTIME COMPLETED:
04:45 PM
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) Christina Valerio and LPA Jamie Ivey-Canady conducted a case management inspection of Peer Home #1. LPAs met with Co-Administrator Monica Butay to ensure the facility is in compliance with applicable statutes and regulations. LPAs confirmed with staff there are zero residents or staff that have displayed any signs or symptoms of COVID-19 in the last 10 days.

During the visit, the LPA conducted interviews with 2 staff. Based on interviews, there are 2 staff on shift except for over night shift, staff get paid bi-weekly, staff have never received a late pay check, and staff have waived lunch breaks. LPAs observed one staff on shift upon arrival. Co-Administrator arrived at the facility 10 minutes after LPA arrival. LPAs learned through review of staff COVID log sign-in sheet that there were 5 days where there were only 1 staff on shift. LPAs reviewed the staff schedule for February 2022, which also showed only 1 staff on shift for multiple hours every day of the week.

The LPA reviewed staff files, resident files, and medication files. LPA observe the facility to have updated information in staff and resident files. Medication files were completed and up to date. LPA observed the facility did not have an updated LIC 500 on file. The LIC 500 on file in the facility was updated in 2017. The LPA conducted a tour of the physical plant and observed 4 residents. LPAs observed signage regarding COVID-19, California Minimum Wage Notice from 2022, and an Emergency Disaster Plan from 2021. LPAs did not observe the facility to have an adequate amount of food. The facility is to have nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days, which the facility did not have at the time of visit.

Based on interviews, file reviews, and observation of the physical plant, it appears the facility is not within compliance with applicable statutes and regulations. Deficiencies can be found on LIC 809-D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was held with Co-Administrator Monica B. and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/23/2022 04:35 PM - It Cannot Be Edited


Created By: Christina Valerio On 02/23/2022 at 03:57 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PEER HOME #1
FACILITY NUMBER: 347004519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2022
Section Cited
CCR
85076(d)(1)

1
2
3
4
5
6
7
85076 Food Service (d)The licensee shall meet the following...requirements: (1)Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidence by:
1
2
3
4
5
6
7
Licensee stated today was the shopping day for the facility. Licensee stated they will be going shopping today and ensure there will enough fresh foods and non-perisable foods moving forward. Licensee to show pictures of food to LPA via e-mail by POC due date.
8
9
10
11
12
13
14
Based on observation, the facility did not ensure to have minimum of one week and fresh perishable foods for a minimum of two days. LPAs observed 5 pieces of fruit, 2 of which were molded, and refridgerators were near empty.
8
9
10
11
12
13
14
Type B
03/02/2022
Section Cited
CCR8080065(a)

1
2
3
4
5
6
7
80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated Administrator Monica works while the other 1 staff is on shift. Licensee will ensure to have atleast 2 direct care staff on shift during AM and PM shift moving forward. Licensee to send a copy of March staff schedule by POC due date.
8
9
10
11
12
13
14
Based on observation/record review, the licensee did not ensure to have stuff necessar to meet needs of all residents. The licensee had only 1 staff on shift mutiple times every day of the week. In the event of a behavior outburst, Resident 1 needs to have 1 staff available for them while the other residents are assisted by another staff members.
8
9
10
11
12
13
14
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:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2