<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004685
Report Date: 05/23/2024
Date Signed: 05/23/2024 09:27:48 AM

Document Has Been Signed on 05/23/2024 09:27 AM - 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ROJO CARE HOME 2FACILITY NUMBER:
347004685
ADMINISTRATOR/
DIRECTOR:		ROJO, MADELYNFACILITY TYPE:
735
ADDRESS:7867 BLACK SAND WAYTELEPHONE:
(916) 735-9112
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 4CENSUS: 3DATE:
05/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Administrator, Madelyn RojoTIME VISIT/
INSPECTION COMPLETED:
09:30 AM
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
On 05/23/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak conducted a case management visit. LPA met with Administrator, Madelyn Rojo and explained the purpose of today's visit. The purpose of today's visit is to follow up on a Special Incident Report (SIR) that was sent to the Department on 05/17/2024.

SIR indicated Alta California Regional Center (ACRC) conducted a Title 17 review on 05/16/2024 and notated a substantial inadequacy regarding medication. SIR notated Resident #1 (R1) medication Scopolamine Patch 1 MG (Apply every 1 patch to clean dry area of skin every 72 hours for excessive drooling) had been signed on the Medication Administration Record (MAR) for every five (5) days. Facility contacted the doctor as soon as this was observed, and no further medical attention is needed due to this error.

This home is required to be in compliance with both California Code of Regulations, Title 17 and Title 22. LPA's visit today is to address the issues found during the Title 17 review and issue deficiencies for the medication error.

Deficiencies are cited pursuant to California Code of Regulations, Title 22, and documented on the attached LIC809D. Failure to submit Proof of Correction (POC) by Plan of Correction date may result in civil penalties.

Exit interview conducted and a copy of the report and appeal rights was left at the facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/23/2024 09:27 AM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 05/23/2024 at 08:51 AM
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: ROJO CARE HOME 2
FACILITY NUMBER: 347004685

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2024
Section Cited
CCR
80075(b)

1
2
3
4
5
6
7
80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Licensee and staff have completed medication administration course. Licensee is to submit proof of course for all staff to LPA by POC due date 05/24/24.
8
9
10
11
12
13
14
Based on the gathered information the facility did not give R1 their medication as prescribed which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Laura Munoz
LICENSING EVALUATOR NAME:Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2