347004525-7-20-2021-27-AS-TTRG-C54W3Q-20210720165620

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347004525
Report Date: 07/20/2021
Date Signed: 07/20/2021 04:56:48 PM

Document Has Been Signed on 07/20/2021 04:56 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:	EMBASSY FOUNTAIN INC. #2		FACILITY NUMBER:	347004525
ADMINISTRATOR:	NITTA, LEILANI M.		FACILITY TYPE:	735
ADDRESS:	10021 MOSAIC WAY		TELEPHONE:	(916) 343-6750
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY: 6		CENSUS: 6	DATE:	07/20/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Leilani Nitta, Administrator		TIME COMPLETED:	04:30 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) Tung Truong arrived at this facility unannounced on 07/20/2021 at 2:15 PM to conduct an annual inspection visit. LPA met with administrator Leilani Nitta and explained the purpose of the visit. Administrator holds current certification #6008957735 and expires on 11/28/2021. The facility is licensed to serve 6 ambulatory developmentally disabled adults. Age range 18 through 59 years. There are currently 6 clients. LPA toured the facility with administrator Leilani Nitta on 07/20/2021 at 2:30 PM. LPA inspected the physical plant including but not limited to the common areas, kitchen, dining area, resident bedrooms; resident bathrooms, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility common areas were furnished and sanitary. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were properly maintained, and the hot water temperature was observed to be 114 degrees Fahrenheit. LPA observed there to be a sufficient amount of perishable and non-perishable food supply on hand. LPA observed knives and toxins to be locked away and inaccessible to residents. Smoke and carbon detectors were in good repair. LPA observed the fire extinguisher is not up to date and fully charge. LPA observed the exterior emergency exit door is clear of derbies. The facility first aid kit is up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA also conducted the infection control domain tool. Continued on 809-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

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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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: EMBASSY FOUNTAIN INC. #2	FACILITY NUMBER: 347004525
	VISIT DATE: 07/20/2021

NARRATIVE

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The facility mitigation plan was submitted to CCLD, and it was approved on 4/28/2021. Facility has routine symptom screening checks for clients, staff, and visitors. The facility has a symptom check binder for staff, clients, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

Administrator was informed to send a copy of the following updated documents to Licensing Office with 15 days: (1) LIC308 Designation of Administrative Responsibility; (2) LIC500 Personnel Report; (3) LIC610 Emergency Disaster Plan; (4) Proof of Current Liability Insurance

The following deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. An immediate civil penalty in the amount of $500 was assessed on 7/20/2021 in regard to the facility not having the fire extinguisher up to date.

Exit interview conducted and copy of report provided. Appeal rights given.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/20/2021 04:56 PM - It Cannot Be Edited

Created By: Tung Truong On 07/20/2021 at 04:03 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: EMBASSY FOUNTAIN INC. #2	FACILITY NUMBER: 347004525
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80020(a)

80020 Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review. The licensee did not ensure fire extinguisher is up to date. Fire extinguisher was last serviced in November 12, 2019. In addition, the fire extinguisher meter showed the fire extinguisher was not fully charged.
	POC Due Date: 07/20/2021
	Plan of Correction
1 2 3 4	Facility staff purchased a new fire extinguisher during today's inspection. LPA observed the new fire extinguisher with receipt of purchase. Purchase documentation to be maintained on file with today's purchase date of 7/20/2021. No further action needed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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-Lee

LICENSING EVALUATOR NAME:

Tung Truong

LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021

LIC809 (FAS) - (06/04)

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