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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004547
Report Date: 12/04/2023
Date Signed: 12/04/2023 02:59:39 PM

Document Has Been Signed on 12/04/2023 02:59 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:TUMAMAO'S RESIDENTIAL FACILITYFACILITY NUMBER:
347004547
ADMINISTRATOR:TUMAMAO, FLORENDAFACILITY TYPE:
735
ADDRESS:8569 VINTAGE PARK DRIVETELEPHONE:
(916) 689-3270
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 4CENSUS: 4DATE:
12/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Therese Tagatac TIME COMPLETED:
03:15 PM
NARRATIVE
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On 12/03/2023 at 12:45 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to conduct case management visit to follow up on a two incident report. LPA met with care staff Dolores Ona and Apolonio Tumamao and explained the purpose of the visit. Care staff called, Direct Care Staff Therese Tagatac to informed that CCLD was present in the home. Direct Care Staff, Therese arrived approximately 40 minutes later to join the visit. The census is 4.

The Department received the first LIC 624 Unusual Incident Report (UIR) on 11/22/2023 regarding an


incident that occurred on 11/20/2023. At 11:30 AM, staff 1 (S1) was providing support to client (C1) as (C1) walked from the bathroom to the living room when (C1) tripped. (S1) was able to catch (C1) from the back to prevent (C1) from falling to the ground. Per (S1), (C1) appeared fine as (C1) did not fall. At 7:00 AM, as staff were preparing for (C1) for bed staff noticed (C1) had difficulty walking. On 11/21/2023, when (C1) woke up, staff noticed that (C1) left foot was slightly swollen with a faint bruise. It was learned that at 3:30 PM, (C1) was seen by Dr. Lao at Dignity Health. Where (C1) was diagnosed with having a fracture on (C1) left foot.

LPA Lee interviewed staff and attempted to interview (C1). LPA Lee observed (C1) sitting in the common area watching TV. LPA Lee observed on (C1) left foot has a ProCare Squared Toe Post-Op Shoe. (C1) appeared to be comfortable and no signs of pain. LPA requested and received a copy of (C1) IPP plan, LIC 625 Appraisal and Needs and Service Plan, Discharge Summary, MAR logs for the month of November, and any service notes related to observation of resident from 11/20/2023-11/23/2023. Based on record reviews it was learned that client did have a fracture and was prescribe ibuprofen for pain. On 11/28/2023 (C1) had an appointment to see a Podiatrist. During this visit, (C1) was given a prescription for a squared toe post op shoe. It was also learned that (C1) has another appointment scheduled for 01/02/2023 at 10:00 AM for left foot follow-up to do another x-ray.

Continued LIC 809-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: TUMAMAO'S RESIDENTIAL FACILITY
FACILITY NUMBER: 347004547
VISIT DATE: 12/04/2023
NARRATIVE
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On 11/30/2023 at 3:31 PM, the department received the second LIC 624 (UIR). The incident occurred on 11/29/2023 regarding medication documentation error. On 11/29/2023, during a Title 17 inspection, (C2) Medication Administration Record (MAR) was reviewed. It was learned that (C2) medication Benztropine 1mg was initiated for 7:00 AM medication pass; however, there was no initialed for (C2) 7:00 PM medication pass. During today’s visit, LPA Lee reviewed (C2) (MAR) log for the month of October, November, and December. Record revealed that (C2) MAR log is complete for the month of October and December; however, for (C2) MAR log for the month of November (C2) medication Benztropine 1 mg was initialed for 7:00 AM pass from 11/01/2023 to 11/31/2023 and from 11/01/2023 to 11/28/2023 (C2) 7:00 PM medication pass was not initialed therefore, it is unclear whether (C2) received (C2) medications.

Per California Code of Regulations (CCR) – deficiency is being cited on the attached LIC 809-D. Appeal
Rights provided. Failure to correct deficiencies may result in civil penalties. An exit interview was held with
Therese Tagatac and a copy of the report was provided at the end of the visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/04/2023 02:59 PM - It Cannot Be Edited


Created By: Pang Lee On 12/04/2023 at 02:04 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: TUMAMAO'S RESIDENTIAL FACILITY
FACILITY NUMBER: 347004547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/08/2023
Section Cited
CCR
80075(b)

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80075(b) Health Related Services
Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by:
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The facility conducted an all staff meeting on 11/29/2023. The administrator is in the process of producing a quality aasurance checklist for the MAR log. Facility will conduct a training in documenting medication pass.
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Based on record review and interviews, the facility did not ensure that (C2) MAR log was initialed for 11/01/2023 to 11/28/2023; therefore, it is unclear whether (C2) received (C2) medications; which poses an immediate health, safety and personal rights risk to residents in care.
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The facility will provide the department with copies of the training materials used and sign in sheets indicating all staff who attended the meeting. POCand the quality assurance checklist will be emailed to LPA Lee by 12/08/2023 by 5:00 PM end of day.

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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023


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