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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390305586
Report Date: 02/02/2021
Date Signed: 02/16/2022 12:10:39 PM


Document Has Been Signed on 02/16/2022 12:10 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/03/2021 08:10 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

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Licensing Program Analyst (LPA) Eric Stone and Licensing Program Manager (LPM) Stephen Richardson spoke with Gernaine Brown on behalf of Licensee/Administrator Esther Johnson at 3:30 pm on 2/2/2021 to conduct a case management visit regarding concerns of reporting requirements and Administrator change.

LPA Stone discussed with Gernaine that there were seven cases of COVID positive test results that were not reported to the Department. Seven records of residents who tested positive for COVID-19 were reviewed by Gernaine on 2/2/21 at 3:30 pm. Gernaine stated that Special Incident Report (SIR) was sent for some residents but is not aware of the actual day it was submitted, or which residents were included in the report. LPM Richardson reminded Gernaine about reporting requirement timeframes when receiving notification of any positive test results in the facility. Gernaine stated that she thought they did report the positive cases to the RO but will need to verify. LPM Richardson had already received the names of the positive residents from test results received on 1/7/2021.

LPA Stone also discussed with Gernaine that a change of Administrator needs to be completed by the due date of 2/9/2021. LPA Stone informed Gernaine that an email will be sent with specific information to submit to the Department by the due date. The Department has received a copy of the Administrator Certificate and fingerprint clearance for the proposed Administrator and is requesting copies of the following for processing: LIC 200, LIC 308, LIC 500, LIC 503.

LPM Richardson asked if the Mitigation Plan Report (LIC 808) had been submitted by the 1/24/2021 deadline. Gernaine answered that they know they sent a mitigation plan in December of last year but not anything in January. LPM Richardson discussed PIN 20-48 and the expectation that the mitigation plan be submitted as outlined in the PIN.

At 04:45 pm, LPA conducted a follow up call with Staff 2 (S2) to clarify questions based on the original phone call with Gernaine.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, Deficiencies are being cited during this meeting. An exit interview was conducted with the S2 via telephone and a copy of this report was provided via email and proposed Administrator will return a signed copy to the Department by end of day 2/3/2021.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Eric StoneTELEPHONE: 916-594-3786
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2021
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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