347005713-6-22-2021-27-AS-TSTH-C48JLS-20210622070912

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005713
Report Date: 06/21/2021
Date Signed: 06/22/2021 07:09:20 AM

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:	DANIEL RESIDENTIAL CARE HOME LLC		FACILITY NUMBER:	347005713
ADMINISTRATOR:	DIALA, JOYCE		FACILITY TYPE:	740
ADDRESS:	4295 AMAPOLA WAY		TELEPHONE:	(916) 717-3263
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	6	CENSUS: 3	DATE:	06/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Helen Agbiriogu		TIME COMPLETED:	10:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/21/21 at 10:15 AM, Licensing Program Analyst (LPA) Suong Teh and LPA Christina Valerio arrived at this facility unannounced to conduct an annual inspection visit. LPA was met by support staff Helen Agniriogu ened upon entry for COVID precautions. LPAs explained the purpose of the visit to support staff. Administrator Emmanuel Dalia ed at 10:46 AM and met with LPAs. LPA explained the purpose of the visit to Administrator. Support staff Helen accompanied LPA on facility tour. LPAs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 3. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing noted. Chemicals and medications were noted to not be accessible to residents in care. LPA also conducted the infection control domain tool. The facility submitted a LIC 808 mitigation plan, which is being reviewed. The facility has central entry point and has implemented screening and sign in procedures at the front door. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing stations throughout, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong Teh	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

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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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: DANIEL RESIDENTIAL CARE HOME LLC	FACILITY NUMBER: 347005713
	VISIT DATE: 06/21/2021

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Water temperature reads 122 F and the facility temperature registered at 77*F. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2-days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.

The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked July/2020. Facility has an emergency food and water supply in a separate storage area in kitchen. LPA requested the following documents to be updated: LIC 500, LIC 610E, LIC 308, LIC 309 and the lease agreement.

Per California Code of Regulations, Title 22, deficiencies was observed during this visit. Exit interview was held and a report was given to Administrator Emmanuel Dalia.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong Teh	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC809 (FAS) - (06/04)

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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: DANIEL RESIDENTIAL CARE HOME LLC	FACILITY NUMBER: 347005713
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/22/2021 Section Cited	1 2 3 4 5 6 7	Maintenance and Operation Water supplies and plumbing fixtures shall be maintained as follows:Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
	8 9 10 11 12 13 14	Based on observation the licessee did not ensure that the water temperature is within an acceptable range. The LPAs observed the temperature to be 122 degress. This poses an immediate risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong Teh	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC809 (FAS) - (06/04)

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