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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004550
Report Date: 09/14/2023
Date Signed: 09/14/2023 12:03:41 PM

Document Has Been Signed on 09/14/2023 12:03 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:SHAKIL'S CARE HOMEFACILITY NUMBER:
347004550
ADMINISTRATOR:KHAN, SHAKILFACILITY TYPE:
735
ADDRESS:12717 HAUSCHILDT ROADTELEPHONE:
(209) 200-3046
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 4CENSUS: 4DATE:
09/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Victoria GomezTIME COMPLETED:
12:15 PM
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On 9/14/23 at approximately 11:45am Licensing Program Analyst (LPA) Jennifer Fain and Licensing Program Manager Liza King arrived at this facility to follow up on an incident report re: a medication that was missed due to the resident spitting it out on two separate occasions. LPA met with the house manager and explained the purpose of the visit.

Two incident reports were received in the CCL office 06/16/23 and 07/09/2023 . Following the first incident the facility put a plan in place to monitor the resident for 10 minutes following medication administration. Following the second incident the facility coordinated with the regional Center and the MD, received a crush order and communicated with the pharmacy. Each medication was observed to have a label on it printed by the pharmacy. LPM also observed the crush order signed by the MD on 07/25/23.

Technical Advice was provided regarding reporting Requirements. Facility provided an in-service to staff on crushing medications.

No deficiencies were observed during the visit, exit interview was conducted with the house manager.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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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