347004525-5-14-2024-27-AS-AVIA-D59UNG-20240514154354

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347004525
Report Date: 05/14/2024
Date Signed: 05/14/2024 03:44:17 PM

Document Has Been Signed on 05/14/2024 03:44 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:	EMBASSY FOUNTAIN INC. #2		FACILITY NUMBER:	347004525
ADMINISTRATOR/ DIRECTOR:	NITTA, LEILANI M.		FACILITY TYPE:	735
ADDRESS:	10021 MOSAIC WAY		TELEPHONE:	(916) 647-4267
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY: 6		CENSUS: 6	DATE:	05/14/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:54 PM
MET WITH:	Leilani Nitta		TIME VISIT/ INSPECTION COMPLETED:	03:50 PM

NARRATIVE

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On 5/14/24, at 2:30pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct an annual continuation visit. The purpose of this visit is to continue the required annual inspection initiated on 3/29/24. LPA met with the administrator Leilani Nitta. Present during this visit were 4 clients in care with 2 staff on duty.

From last visit on 3/29/24, it was discovered during client record review that licensee did not ensure all facility staff completed training prior to assisting Client#1 (C1) with their glucose testing. Per review of C1’s restricted health care plan dated 9/29/2022, only one staff was trained by a licensed professional. Per interview with the administrator, Leilani Nitta, on 3/29/24, current staff were not trained prior to assisting client with their glucose testing. Interview with Staff#1 (S1) on 3/29/24, staff are the ones that perform the glucose testing for C1.

The following deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. Note that failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted with Leilani Nitta 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 03:44 PM - It Cannot Be Edited

Created By: Arvin Villanueva On 05/14/2024 at 03:24 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: EMBASSY FOUNTAIN INC. #2	FACILITY NUMBER: 347004525
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80092.8(a)(2)(A)(2)

80092.8 Diabetes: (a) A licensee of an adult CCF may accept or retain a client who has diabetes if all of the following conditions are met:...2. The licensee ensures that facility staff responsible for glucose testing receive training from a licensed professional as specified in Sections 80092.1(k) through (k)(2). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above. It was discovered that 4 of 4 staff files reviewed did not complete training relating to client's specialized care needs by a licensed professional prior to assisting client in care with their glucose testing. Additionally, client file review indicated only one staff was trained by a licesed professional for assisting client with their glucose testing. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/21/2024
	Plan of Correction
1 2 3 4	Corrected on site: Administrator provided copy of staff training relating to assisting client with their glucose testing. Per review, training was done by a licensed professional. on 4/4//24. Licensee will ensure all staff receive training prior to providing care to client with restricted health condition specified in Section 80092.

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:

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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