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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005733
Report Date: 02/19/2021
Date Signed: 02/19/2021 06:18:41 PM

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:SIGNATURE LIVING RCFEFACILITY NUMBER:
347005733
ADMINISTRATOR:ENERO,EDGARFACILITY TYPE:
740
ADDRESS:7315 POCKET ROADTELEPHONE:
(916) 346-4128
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 5DATE:
02/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Hazel Napalan FloresTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a subsequent complaint visit during which time the following deficiencies were observed during the investigation.

LPA observed pictures of R1 for a complaint, however, LPA also observed R1 holding a box of Advil while sitting in the common area with other residents.

LPA observed while reviewing R1’s facility file that the Preplacement Appraisal Information (LIC603) was incomplete with only the second page completed.

LPA obtained information that R1 was released from the hospital to a Rehabilitation Center once ready to return to the facility the resident was relocated to a different facility. There was no documentation that the responsible party was notified of or agreed to the relocation and the bed was not held for residents return but was filled by a new resident which constitutes an illegal eviction.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted with Hazel Napalan Flores via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.













SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
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 3
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: SIGNATURE LIVING RCFE
FACILITY NUMBER: 347005733
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2021
Section Cited

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Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident…readily available to… licensing agency staff.
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This requirement is not met as evidenced by: During a document review, LPA observed the LIC603 to be incomplete.
Based on review of R1s file documents, LPA observed the licensee did not ensure resident records are completed, signed, and dated as required by Title 22 Regulations. This violation poses a potential health, and safety risk to residents in care.
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Type B
02/19/2021
Section Cited

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Eviction Procedures-The licensee shall be permitted to evict a client by serving the client with a 30-day written notice to quit for... A needs and services plan modification has been performed...which determined that the client's needs cannot be met by the facility and the client has been given an opportunity to relocate as specified in Section 85068.3(b)(3).
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This regulation was not met as evidence by: LPA obtained information from the Licensee that R1 was relocated to a different facility upon discharge from the rehabilitation center. The licensee did not ensure the responsible party of R1 agreed or notified of the relocation. This poses a potential risk to clients 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: SIGNATURE LIVING RCFE
FACILITY NUMBER: 347005733
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2021
Section Cited

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Incidental Medical and Dental Care
The following requirements shall apply to medications which are centrally stored:
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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This requirement is not met as evidenced by: LPA observed R1 holding a box of Advil while sitting in the common area.
Based on interviews, Licensee did not centrally store medication. This violation poses an immediate health, and safety 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3