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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005412
Report Date: 09/22/2023
Date Signed: 09/22/2023 12:39:19 PM


Document Has Been Signed on 09/22/2023 12:39 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:VIRGINIA DENISE COUNTRY HOMEFACILITY NUMBER:
347005412
ADMINISTRATOR:FERMO, AILEENFACILITY TYPE:
740
ADDRESS:2305 VIRGINIA DENISE LANETELEPHONE:
(916) 813-0460
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY:6CENSUS: 3DATE:
09/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Aileen Fermo-CantorTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived to the facility to conduct a case management visit regarding an incident report the Department received. LPAs met with Administrator, Aileen Fermo-Cantor, who arrived to the facility shortly after LPAs.

LPAs and Administrator discussed the received special incident report regarding an incident that occurred on 9/20/2023 when R1 was hospitalized after R1 collapsed on the floor. Administrator provided LPAs time of when emergency medical services was contacted.

LPAs and Administrator conducted a tour of R1's room, and additionally, LPAs conducted a review of R1's files.

At this time, LPAs requested Administrator to submit a copy of LIC 500, R1's 2022-2023 Individual Program Plan, R1's Behavioral Intervention Progress Report, Physician's Report For Resident Care Facilities For the Elderly, Admission Agreement, R1's list of medication, R1's special incident report and R1's death report to be emailed to LPA Yang by close of business Friday 09/22/2023.

LPA Yang offered to take R1's file to create copies as LPAs observed Administrator to be in distress but Administrator informed LPA she will do it as she is not aware Licensing Department can remove files from the facility. LPAs provided Administrator a copy of California Code Regulation 87506 Resident Records.

Result of today's visit, no deficiencies cited as incident is under review.

Exit interview, a copy of report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
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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