392700250-6-2-2021-27-AS-TWHE-C3FQA8-20210528115931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700250
Report Date: 05/28/2021
Date Signed: 06/02/2021 08:55:30 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:	OPTIMUM SENIOR CARE HOME		FACILITY NUMBER:	392700250
ADMINISTRATOR:	PRISCILLA QUITEVIS		FACILITY TYPE:	740
ADDRESS:	209 N SCHOOL STREET		TELEPHONE:	(209) 298-7258
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	24	CENSUS: 23	DATE:	05/28/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Priscilla Quipevis, Administrator		TIME COMPLETED:	12:10 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 05/28/2021 at 9:35am, Licensing Program Analyst (LPA) T. White spoke with Licensee, Sherwan Matammu regarding facility risk assessment questions. Licensee confirmed no staff or clients have experienced symptoms within the last 10 days. At 9:50am, LPA T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with Administrator, Priscilla Quipevis and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 24 non-ambulatory residents, which 6 may be on hospice. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 111 and 109 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. LPA observed smoke detectors is interconnected with the fire department. Fire extinguisher was last serviced on January 23, 2021. Administrator stated she is waiting on guidance from referral agency for the mitigation plan corrections. - LPA observed carbon monoxide was not in operating condition during inspection. - LPA observed front door with tape around the door knob. LPA observed front door in disrepair. - LPA observed a emergency door in disrepair. - LPA observed two staff members not properly wearing masks. - LPA observed residents shared bedroom blinds were not in good condition. Report continues on 809C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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: OPTIMUM SENIOR CARE HOME	FACILITY NUMBER: 392700250
	VISIT DATE: 05/28/2021

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/11/2021:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610 Emergency Disaster Plan

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted with Administrator. A copy of report and appeal rights given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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: OPTIMUM SENIOR CARE HOME	FACILITY NUMBER: 392700250
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.1(a)(2)

Personal Rights of Residents in all Facilities

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation the licensee did not comply with the section cited above in 87468.1(a)(2). LPA observed two staff members did not properly have mask on which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/11/2021
	Plan of Correction
1 2 3 4	Administrator agreed to conduct training with all staff and submit proof by POC date.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: OPTIMUM SENIOR CARE HOME	FACILITY NUMBER: 392700250
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 1569.311. LPA observed one missing carbon monoxide which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/11/2021
	Plan of Correction
1 2 3 4	Adminsitrator agreed to obtain a new carbon monoxide and submit proof by POC date.

Type B

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
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 87303(a). LPA observed front door and emergency door in disrepair and blinds in shared bedrooms in disrepair, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/11/2021
	Plan of Correction
1 2 3 4	Adminsitrator agreed to repair doors and blinds and submit proof by POC date.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC809 (FAS) - (06/04)

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