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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005345
Report Date: 12/29/2022
Date Signed: 12/29/2022 04:38:04 PM

Document Has Been Signed on 12/29/2022 04:38 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:PEER HOME 2FACILITY NUMBER:
347005345
ADMINISTRATOR:GEOFFREY A LOPEZFACILITY TYPE:
735
ADDRESS:7727 MASTERS STREETTELEPHONE:
(916) 509-9450
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
12/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Facility StaffTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit. LPA met with facility staff, and explained the purpose of the visit. LPA called Administrator Geoffrey to inform of visit. Administrator created the POC over the phone and designated staff to sign the documents.

LPA received a Facility Action Report dated 12/14/2022. According to records, the facility was not within compliance of Title 17 regulations for Medications and Training Plans.  During the visit the following was cited:
    • The MAR incorrectly states the client is taking Perphenazine 8mg. The prescription label and prescription from the pharmacy both state the client is taking Perphenazine 16mg.
    • Acetaminophen 500mg with expiration date of 12/2023 was not logged on the Centrally Stored Medication Log.
    • The Peer Home #2 Program Design identifies monthly staff training. There was no documentation of monthly staff meetings present during the review.

LPA reviewed the centrally stored log, medication administrator records, and training plans. LPA found that a training was completed with 1 staff on 12/22/22 for the following topics (Facility Program Design, Individual Program Plan, Client's Rights & Responsibilities, Personal Rights, Medication Assistance, Health & Emergency Procedures, Special Incident Reporting, Client Abuse Identification Reporting). Medication records show that the facility fixed the errors found on 12/14/2022.

Based on records review and observations, deficiencies are being cited today on LIC 809 - D. Appeal rights provided. Failure to correct deficiencies may result in civil penalties. An exit interview was held with facility staff, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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 12/30/2022 01:23 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/30/2022 01:20 PM


Created By: Christina Valerio On 12/29/2022 at 02:55 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PEER HOME 2
FACILITY NUMBER: 347005345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2023
Section Cited
CCR
80075(k)(3)

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80075 Health Related Services (k)The following requirements shall apply to medications which are centrally stored: (3)All medications shall be labeled and maintained in compliance… This requirement was not met as evidenced by:
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Licensee stated a new medication system will be implemented. All staff will be trained on the system. LPA to receive a copy of the new medication system and in-service training by POC due date of 01/06/2023.
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Based on observations and records review, 2 out of 4 client medication records were not maintained in compliance of laws and regulations. This poses a potential health and safety risk to residents in care.
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This report was amended to update the correct deficiency code. Administrator was informed of the amendment and provided a copy.
Type B
01/06/2023
Section Cited
ILS80064(a)(7)

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80064 Administrator - Qualifications and Duties
(a) The administrator shall have the following qualifications: (7) Ability to…train, and evaluate qualified staff…This requirement was not met as evidenced by:
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Licensee stated training plans will be put in place for December 2022 and all of 2023. LPA to receive a copy of intended training for 2023 and copy of in-service training provided for December 2022 by POC due date 01/06/2023.
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Based on records review, the licensee did not ensure the administrator provided monthly training as discussed in the facilities plan of operation. This poses a potential health and safety risk to residents in care.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022


LIC809 (FAS) - (06/04)
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