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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004960
Report Date: 10/03/2024
Date Signed: 10/07/2024 02:54:07 PM


Document Has Been Signed on 10/07/2024 02:54 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 MANORFACILITY NUMBER:
347004960
ADMINISTRATOR:APUYA, MARIAFACILITY TYPE:
740
ADDRESS:2629 EASTERN AVENUETELEPHONE:
(916) 972-9668
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:13CENSUS: 11DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Geronima BautistaTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPAs Moleski and Williams met with facility administrator Geronima Bautista and explained the purpose of the visit.

LPAs Moleski and Williams reviewed 5 resident files (R1-R5) and two staff files (S1-S2).

LPAs Moleski and Williams toured the facility with Bautista and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. LPA Williams observed broken closet doors in 2 bedrooms. One room had closet doors that were broken and barring the resident from accessing their clothes. The second bedroom had a closet door which was off the railing. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 98.7 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees. Licensee was given a Technical Violation for the water temperature. Licensee turned water up while LPAs Moleski and Williams were conducting the inspection.

LPAs Moleski and Williams observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPAs Moleski and Williams observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPAs Moleski and Williams observed a locked cabinet for the storage of medication. LPAs Moleski and Williams observed locked cabinets for the storage of cleaning solutions and knives. LPA Williams observed a prescription medication bottle, in a unlocked drawer, in the kitchen. LPA Williams observed detergent and bleach unlocked in the laundry room.

LPA Moleski interviewed one staff member (S3) and two residents (R2,R5). This facility is being cited per 22 CCR Section 87303(a), 87465(h)(2) and 87309(a). An exit interview was held with Geronima Bautista. Appeal rights and a copy of this report were emailed to Bautista.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
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 3


Document Has Been Signed on 10/07/2024 02:54 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: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
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
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Based on observation, the licensee did not repair closet doors which barred resident from accessing their clothes, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee agrees to send statement of action to complete repairs on closet doors by POC due date. Repairs to be complete
by 10/17/2024 and Licensee will email pictures of repaired closet doors. Holly.williams@dss.ca.gov
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not lock up laundry detergent, bleach, and Downy scent pellets, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee locked up detergents and bleach during inspection. POCl is cleared.
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-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/07/2024 02:54 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: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not lock up prescription medication bottle, in the drawer, and in the kitchen. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee locked up prescription bottle during inspection. POC cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3