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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004550
Report Date: 08/16/2022
Date Signed: 08/16/2022 04:02:37 PM

Document Has Been Signed on 08/16/2022 04:02 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: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: DATE:
08/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:Victoria Gomez, House ManagerTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) R. Campbell conducted an unannounced Case Management on this date and met with House Manager Victoria Gomez, The case management visit pertains to medication errors.

During the visit, the LPA spoke with House Manager Victoria Gomez regarding PRN medications. LPA Campbell reviewed the Centrally Stored Medication Log and observed that the start dates were inconsistent in comparison with the first dose given out. Staff either entered the the date medication was received as the start date or did not enter a start date at all. LPA Campbell interviewed the House Manager, who described the Centrally Stored Medication Log process. She also provided the binders for all residents who receive medication.

After record reviews and interview, it was determined that the facility was not correctly updating the start date for medications. Staff either did not understand the definition of the start date or did no know tot enter a start date.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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 08/16/2022 04:02 PM - It Cannot Be Edited


Created By: Renee Campbell On 08/16/2022 at 02:59 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: SHAKIL'S CARE HOME
FACILITY NUMBER: 347004550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2022
Section Cited
CCR
85075(b)

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(b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs. This requirement is not met as evidenced by inconsistent record keeping for medication start dates.
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The Administrator agrees to conduct staff training on medication management for all staff by POC Date. Facility will email LPA training documents by POC date 09/05/2022 to renee.campbell@dss.ca.gov.

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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:Liza King
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022


LIC809 (FAS) - (06/04)
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