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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700250
Report Date: 05/01/2023
Date Signed: 05/01/2023 05:25:53 PM

Document Has Been Signed on 05/01/2023 05:25 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:OPTIMUM SENIOR CARE HOMEFACILITY NUMBER:
392700250
ADMINISTRATOR:PRISCILLA QUITEVISFACILITY TYPE:
740
ADDRESS:209 N SCHOOL STREETTELEPHONE:
(209) 298-7258
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 24CENSUS: 23DATE:
05/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Priscila Quitevis, AdministratorTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Annual 1-Year Required visit on this date. LPA met and toured with Administrator, Priscilla Quitevis. The administrator currently holds a certificate (#6009772740) that expires on 10/14/2023

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 16 total bedrooms of which 14 bedrooms are occupied by the residents and 2 bedrooms are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 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 108 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/05/2023. Three of five fire extinguishers were out of date. Administrator will purchase new ones within 24 hrs. First aid kit was observed to be complete.
LPA reviewed 3 of 8 staff record files and the facility has sufficient staffing to provide the services needed to meet the residents’ needs . One staff member did not have a negative TB test on file . The facility serves residents with mental illness and staff have received the necessary training hours specific to mental illness. LPA reviewed 3 of 23 residents’ files.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 05/05/2023:.

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
Liability Insurance

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

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2023
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 05/01/2023 05:25 PM - It Cannot Be Edited


Created By: Renee Campbell On 05/01/2023 at 04:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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87411(f) General. Good physical health of personnel shall be verified by a T.B. test, performed and signed by a physician not more than six months prior to or seven days after employment. This requirement was not met as evidenced by : Based on observation, interveiws and records reviews, the licensee did not ensure personnel had proof of negative TB tests on file which poses a potential Health, Safety or Personal Rights risk to residents in care.
POC Due Date: 05/05/2023
Plan of Correction
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1. Licensee will verify all personnel have proof of negative TB tests on file with a physician signed X-Ray or health screening and will submit scanned copies to LPA at renee.campbell@dss.ca.gov.
Section Cited
Deficient Practice Statement
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87202(a) (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services. Based on observation, interview and record review the lincesee did not ensure fire extinguisher is up to date. Fire extinguisher was last serviced on 02/2017. This poses a potential health and safety risk to residents in care.
POC Due Date: 05/03/2023
Plan of Correction
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1. Licensee will either provide a copy of prior inspection approval for the existing fire extinguishers or purchase three new fire extinguishers with the receipt taped to the extinguisher
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:Emerita Curiel
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


LIC809 (FAS) - (06/04)
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