347005713-5-21-2024-27-AS-PLEE-D5GUFS-20240521153314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005713
Report Date: 05/21/2024
Date Signed: 05/21/2024 03:33:24 PM

Document Has Been Signed on 05/21/2024 03:33 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:	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: 6	DATE:	05/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:48 PM
MET WITH:	Helen Agbiriogu and Irene Iberi		TIME COMPLETED:	03:46 PM

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 05/21/2024 at 12:48 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care giver, Helen Agbiriogu and Irene Iberi who then called administrator Joyce Diala to informed that CCLD is present. Administrator stated that she won’t be able to join the visit. LPA Lee explained the purpose of today’s visit. Administrator Certificate # 6035237740 expires on 08/05/2025. The current census is 6 with 2 facility staff. This facility is a single story building licensed to served six (6) residents. Room 1 and 3 are cleared for non-ambulatory residents and room 2 are cleared for ambulatory residents. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, residents’ bedrooms, residents’ bathrooms, laundry room, staff room, garage, and outside courtyards of the facility to ensure compliance with Title 22 regulations. It was observed the facility was free of odor and clean. LPA Lee observed in resident bedroom # 3 the sliding screen door was not in good repair. LPA Lee observed care staff Helen tried to put the screen back on the rail and was not able to put the sliding screen back on. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee toured the kitchen and observed the facility had sufficient seven-day non-perishable food supplies. It was observed that two-day perishable food supplies were not sufficient for 6 residents in care. Hot water temperature was measured at 1110.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Grab bars and non-slip mat were observed to be stable and in good repair at this time. Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

Document Has Been Signed on 05/21/2024 03:33 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DANIEL RESIDENTIAL CARE HOME LLC	FACILITY NUMBER: 347005713
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(8)

Incidental Medical and Dental Care Services

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above. The administrator did not ensure that there were a complete first aid kit in the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	Administrator agrees to purchase a first aid kit with a first aid manual and send LPA Lee a photo and receipt of purchased to LPA Lee at pang.lee@dss.ca.gov by 05/31/2024 end of day 5:00 PM.

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review the licensee did not comply with the section cited above. . Records reviewed indicated that resident 1 (R1) Quetiapine 25 MG medication not stored in its originally received container. The instruction for the medication is to take one-half tablet by mouth. It was learned that care staff pre-cut the tablet and stored the half tablets in an extra container and created a label for the Quetiapine medication. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	Administrator agrees to review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. Administrator will ensure that all residents medications are kept in it's orginal container. POC due by 05/31/2024 by end of day 5:00 PM.

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	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 05/21/2024 03:33 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DANIEL RESIDENTIAL CARE HOME LLC	FACILITY NUMBER: 347005713
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, LPA Lee observed in resident bedroom # 3 the sliding screen door was not in good repair. LPA Lee observed care staff Helen tried to put the screen back on the rail. Care staff stated that she was not able to put the screen back on the rail. This posed a potential room risk to residents in care.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	Administrator agrees to fix the sliding screen and send LPA Lee a photo to show that the sliding screen is fix and placed back on resident room #3. POC due to LPA Lee by 05/31/2024 by end of day 5:00 PM.

Type B

Section Cited

CCR

87412(a)

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview LPA Lee also requested to review administrator Joyce Diala’s file, and it was learned that facility staff was not able to be located administrator's file. A brief interview was conducted with administrator Diala, who stated that she is not sure why her file is not at the facility and will follow-up on her file.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	Administrator agrees to ensure that all facility staff files are on the premises at all times. Administrator will email LPA Lee her administrator file to LPA Lee by POC date 05/31/2024 by end of day 5:00 PM.

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	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 05/21/2024 03:33 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DANIEL RESIDENTIAL CARE HOME LLC	FACILITY NUMBER: 347005713
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview LPA Lee reviewed 5 out of 6 resident files and based on record review two resident diagnosed with dementia does not have a current LIC 602 Physician Report in their files.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	Administrator agrees to ensure that all facility residents with dementia has an updated LIC 602 Physician report annually. Administrator will email LPA Lee appointment dates for (R2) and (R3) to have LIC 602 updated. Administrator will then email LPA Lee the new LIC 602. POC due 05/31/2024 by end of day 5:00 PM.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DANIEL RESIDENTIAL CARE HOME LLC	FACILITY NUMBER: 347005713
	VISIT DATE: 05/21/2024

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
26
27
28
29
30
31
32

Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the hallway and was last serviced on 07/17/2024. LPA Lee observed the facility has a has a public telephone in the common area and the facility has the required posters posted. Facility thermostat observed at 73 degrees Fahrenheit. LPA Lee observed toxins located in the hallway closet and kept locked and inaccessible to residents. LPA Lee observed sharp knives kept locked and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed and compared 3 out 6 medication administration record (MAR) along with residents’ medications. Records reviewed indicated that resident 1 (R1) Quetiapine 25 MG medication not stored in its originally received container. The instruction for the medication is to take one-half tablet by mouth. It was learned that care staff pre-cut the tablet and stored the half tablets in an extra container and created a label for the Quetiapine medication. LPA Lee asked to inspect the facility’s first aid kit and care staff were not able to provide LPA Lee the first aid kit other than bandages. LPA Lee requested resident and staff files for review. LPA Lee reviewed 5 out of 6 resident files and based on record review (R2) and (R3) diagnosed with dementia does not have a current LIC 602 Physician Report in their files. LPA Lee reviewed 2 staff files and they were complete. LPA Lee also requested to review administrator Joyce Diala’s file, and it was learned that facility staff was not able to be located administrator's file. A brief interview was conducted with administrator Diala, who stated that she is not sure why her file is not at the facility and will follow-up on her file. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by 05/31/2024 by 5:00 PM by end of day:

(1) LIC 308 Designation of Administrative Responsibility

(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

Page: 5 of 5