347004960-8-31-2023-27-AS-PLEE-CV8R5W-20230831124348

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347004960
Report Date: 08/31/2023
Date Signed: 08/31/2023 12:44:05 PM

Document Has Been Signed on 08/31/2023 12:44 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:	EASTERN MANOR		FACILITY NUMBER:	347004960
ADMINISTRATOR:	APUYA, MARIA		FACILITY TYPE:	740
ADDRESS:	2629 EASTERN AVENUE		TELEPHONE:	(916) 972-9668
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	13	CENSUS: 10	DATE:	08/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Maria Apuya and Geronima Bautista		TIME COMPLETED:	01:00 PM

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 08/31/2023 at 8:00 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator, Maria Apuya and administrator assistant, Geronima Bautista. LPA Lee explained the purpose of the visit. Maria Apuya and Geronina Bautista assisted with today’s visit. Administrator certificate # is 6005486740 and will expire on 07/19/2024. The current census is 10 with 3 facility staff. This facility is a single story building licensed to serve thirteen (13) non-ambulatory residents and approved for 7 hospice residents. The LPA Lee toured the facility with Geromina Bautista at 8:30 AM. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed resident bathrooms #1, #2, and #3 did not have non-slip mat; however, during today’s visit administrator had another staff purchased three non-slip mat and it was placed in the three resident bathrooms. LPA Lee observed the facility to be free of odor and clean. LPA Lee observed the sliding door in the dinning area not in good repair. The sliding screen is broken and has a tear. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee observed sufficient seven day non-perishable and two day perishable food supplies. LPA Lee observed 3 condemns in the refrigerator had expired. Hot water temperature was measured at 130.5 degrees Fahrenheit in resident bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit. Licensee adjusted the hot water and LPA Lee remeasured the hot water and it then measured at 105.6 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher was last serviced on 04/14/2023. Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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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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: EASTERN MANOR	FACILITY NUMBER: 347004960
	VISIT DATE: 08/31/2023

NARRATIVE

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The last fire drill was conducted in July of 2023. LPA Lee observed the facility has a has a public telephone in the common room and one in the kitchen. The facility has the required posters posted. The facility has infection control plan and has an emergency disaster plan. Facility thermostat observed at 73 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed 3 out of 3 Centrally Stored Medication Destruction Record (CSDMR) and 2 out of 3 (CSDMR) was not accurate. First aid kit was checked and is complete. LPA Lee requested resident and staff files for review. LPA Lee reviewed 5 out of 10 resident files and 5 out of 11 staff files and they were complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by 09/08/2023 by 5:00 PM by end of day:

(1) LIC 308 Designation of Administrative Responsibility

(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D, LIC 9102, and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/31/2023 12:44 PM - It Cannot Be Edited

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: EASTERN MANOR	FACILITY NUMBER: 347004960
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. Licensee did not ensure expired food are thrown away. LPA Lee observed 3 items pulled out of the refrigerator had been expired, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	Licensee will develop a monthly schedule for cleaning the refrigerator so that expired goods will be disposed of immediately. This schedule will be submitted to LPA Lee at pang.lee@dss.ca.gov by POC date 09/08/2023 by end of day 5:00 PM.

Type B

Section Cited

CCR

87303(a)

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above. Licensee did not ensure the facility was in good repair. LPA Lee observed the sliding door screen is broken with a tear, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	Licensee agrees to have the sliding door screen replace and installed. Licensee will send a picture of the new sliding door and a video of the sliding door by POC date 09/08/2023 by 5:00 PM by end of day to LPA Lee at pang.lee@dss.ca.gov.

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	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 08/31/2023 12:44 PM - It Cannot Be Edited

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: EASTERN MANOR	FACILITY NUMBER: 347004960
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(4)

87465(a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of resident and facility records, the licensee did not ensure and maintain an accurate centrally stored medications log for R1 and R2. R1 and R2 medication start date is not accurate and clear which caused the count of medication being administer conflicting with the count of medication in the bubble pack, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	Licensee agrees to write down the exact date medication start date is instead of using quotation mark which does not reflect the exact date medication start date begins. Licensee agrees to keep an current and accurate centrally store medication log. Licensee agrees to read the regulation cited and write a statement acknowledging of understanding of the regulation. Licensee will email statement to LPA Lee by POC date 09/08/2023 by 5:00 PM by end of day.

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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