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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005713
Report Date: 05/20/2022
Date Signed: 05/20/2022 01:48:32 PM


Document Has Been Signed on 05/20/2022 01:48 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:DANIEL RESIDENTIAL CARE HOME LLCFACILITY NUMBER:
347005713
ADMINISTRATOR:DIALA, JOYCEFACILITY TYPE:
740
ADDRESS:4295 AMAPOLA WAYTELEPHONE:
(916) 717-3263
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 4DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Joyce DialaTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio and LPA Jamie Ivey Canady arrived to the facility unannounced to conduct the required annual inspection. LPAs were met by Staff 2 (S2), whom was not wearing a mask once LPAs entered the home. LPAs requested Administrator Joyce Diala to be present during the visit. Administrator arrived 20 minutes later.

Upon entering the facility, LPAs observed the home to be malodorous, a smell resembling feces, fish, and dust. LPAs observed a resident in the home at the dinning table. She appeared to be eating breakfast. There were food pieces on the floor, food all over the table, and crumbs from other residents from previous meals. LPAs started to wipe down the kitchen countertop to set up equipment. LPAs observed tiny unidentified bugs, old food scraps, dried sticky residue, and dust after wiping the counters. The counter tops were filled with old plates, used plastic containers, foil wrapped plates with food residue, and used hand towels.

Fire extinguishers was up to date with last check on 03/12/2022. No emergency exits were obstructed. Facility temperature in the home was 74* degrees, which is within the required range. The facility was observed to have an adequate supply of non-perishable and perishable foods.

Bedrooms had necessary furniture: bed, chair, night stand, light, and a dresser. Bathrooms had a trash can with a close lid, paper towels, and soap. 2 bedrooms and 1 bathroom were observed to have holes in the wall caused by the door knob.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, deficiencies were found and can be found on LIC 809-D. Failure to correct the deficiency may result in civil penalties. An exit interview was conducted. Administrator Joyce Diala refused to sign. Signature will be obtained on the hard printed copy and put in the facility file. Administrator to send signed copy via fax to the department by COB 05/20/22.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
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 05/20/2022 01:48 PM - It Cannot Be Edited

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: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 common areas, 1 out of 2 bathrooms, and 2 out 4 bedrooms, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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Licensee stated she will have a professional cleaning company come out to deep clean the entire home including kitchen appliances, kitchen area, common areas, bedrooms, and bathrooms. Licensee stated she will ensure a pest control company will come out to service the home and inspect for possible bed bugs or other pest. Licensee to train staff on cleaning procedures. Licensee to cover holes in the wall. Licensee to send contracts and proof of appointments/service and copy of in-service training sign in sheet with topics covered by POC due date 05/21/2022.
Type A
Section Cited
CCR
87307(d)3(B)
87307 Personal Accomodations and Services(d) The following space and safety provisions shall apply to all facilities: (3) All persons shall be protected against hazards within the facility through provision of the following:(B) Information and instruction regarding life protection and other appropriate subjects

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 2 staffs did not wear a mask, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2022
Plan of Correction
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Licensee stated staff will wear mask moving forward and go over recent PINs regarding mask mandates. Licensee to send LPA proof of training via fax by COB 05/21/2022

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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
LIC809 (FAS) - (06/04)
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