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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005345
Report Date: 02/07/2023
Date Signed: 02/07/2023 04:16:59 PM

Document Has Been Signed on 02/07/2023 04:16 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:
02/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Monica ButayTIME COMPLETED:
04:30 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 newly appointed Administrator Monica Butay, and explained the purpose of the visit.

On 01/13/23, Alta Regional Center Liaison, Jazmin K., made an unannounced visit. During the visit, it was discovered that Resident 1 (R1) had a medication prescribed; however, there was no start date noted in the Centrally Stored Log. Based on records review and observation, a total of 8 pills should have been administered. According to an interview with Administrator Monica, their records show that the resident did receive those 8 pills.

The facility was cited for 80075(k)(3) on 01/06/2023. Due to a repeat violation, a civil penalty in the amount of $1000.00 will be assessed on today's visit.

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 to Administrator Monica.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2023
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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Document Has Been Signed on 02/07/2023 04:16 PM - It Cannot Be Edited


Created By: Christina Valerio On 02/07/2023 at 03:15 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: PEER HOME 2
FACILITY NUMBER: 347005345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2023
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 to send staff signatures acknowledging they have reviewed facility medication policies and procedures by POC due date. Licensee to send LPA a statement confirming that the records have been reviewed each week until 03/03/2023.
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Based on observations and records review, 1 out of 4 client medication records were not maintained in compliance of laws and regulations. This poses an immediate 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: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023


LIC809 (FAS) - (06/04)
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