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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005431
Report Date: 01/26/2024
Date Signed: 01/26/2024 12:55:04 PM

Document Has Been Signed on 01/26/2024 12:55 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:ALL-HEART SENIOR CARE HOMESFACILITY NUMBER:
347005431
ADMINISTRATOR:SAFADY, MIRIAMFACILITY TYPE:
740
ADDRESS:6621 S. LAND PARK DRIVE.TELEPHONE:
(916) 802-3473
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 6DATE:
01/26/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Debbie DillmanTIME COMPLETED:
01:15 PM
NARRATIVE
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On 1/26/24 at 11:00am, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced plan of correction (POC) inspection to ensure the facility has corrected previously cited deficiencies and to ensure the facility is documenting medication administration appropriately.

LPA reviewed and obtained copies of training materials and documentation of training for staff members administering medications. LPA reviewed medication administration log and observed medications administered but not documented on the medication administration record for all six residents in placement. LPA discussed with missing documentation with the facility administrator and discussed a new plan of correction.

The following deficiency is cited per California Code of Regulations, TITLE 22. An immediate civil penalty was issued due to the observation of a repeat violation.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
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 01/26/2024 12:55 PM - It Cannot Be Edited


Created By: Kevin Gould On 01/26/2024 at 12:26 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ALL-HEART SENIOR CARE HOMES
FACILITY NUMBER: 347005431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2024
Section Cited
CCR
87465(a)(1)

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Incidental Medical and Dental Care Services: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. this requirement was not met as evidenced by LPAs review of medication administration records where LPA observed
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Facility will submit a written plan of correction indicating the steps the facility will take to ensure the medications administered to residents are documented immediatly once given to residents and how the facility will implement the plan of correction.
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missing documetnation for all six residents in placement which poses a potential health, safety and personal rights 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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024


LIC809 (FAS) - (06/04)
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