392700332-3-18-2021-27-AS-ABOE-BZ8TW2-20210318150450

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700332
Report Date: 03/18/2021
Date Signed: 03/18/2021 03:05:22 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:	A PLACE CALLED HOME II		FACILITY NUMBER:	392700332
ADMINISTRATOR:	SIMONE A PIERRE JEROME		FACILITY TYPE:	740
ADDRESS:	25820 MAGNOLIA AVE		TELEPHONE:	(209) 986-3949
CITY:	ESCALON	STATE: CA	ZIP CODE:	95320
CAPACITY:	11	CENSUS:	DATE:	03/18/2021
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Brandi Vargas		TIME COMPLETED:	03:10 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	Licensing Program Analyst (LPA) Ashley Boothe, conducted an unannounced Health and Safety visit on 3/18/2021 with facility Administrator (ADM) Brandi Vargas. LPA arrived at facility at 10:45am and Licensee Lesley Pinola designated ADM in her absence. LPA was allowed entry and was accompanied by ADM on facility tour. As of today, current census is 6 residents of which 6 are Hospice, 5 are ambulatory, 1 are non ambulatory, and 0 are bedridden. The facility licensed to served 11 non ambulatory and hospice waiver for 6. It is a six bedroom, three bath house with a living room, dining room, kitchen, and garage. Residents have access to all areas excepted locked laundry room. 4 of 4 staff observed with criminal record clearance and 3 of 4 staff associated in the Licensing Information System. Three staff and four resident records reviewed. LPA was screened for COVID precautionary measures including temperature check and CDC updated COVID questionnaire. COVID precautionary signs for social distancing were observed in common areas. PPE was available. Observed required furniture, and lighting throughout the facility. The temperature inside the facility measured at 71F which is within the required range of 68-85F. Hot water measured in the kitchen faucet to be at 106.7F, 118F and 107.2F in restroom one, 105.4F and 108.5F in restroom two, and 106.7 F in restroom three within regulatory range of 105 F and 120 F. Restrooms observed with grab bars and non slip mats, soap, paper towels and hand washing signs. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. Fire extinguisher(s) purchased on 2/17/2021 and 3/15/2021, smoke and carbon monoxide detector(s) in the home. Continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2021

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: A PLACE CALLED HOME II	FACILITY NUMBER: 392700332
	VISIT DATE: 03/18/2021

NARRATIVE

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Continued from 809.

Observed chemicals locked in the laundry room including EPA registered disinfectants. .

Observed kitchen knives locked and secured in the kitchen pantry. Observed kitchen was in good condition and clean. Food supply for 2-day perishable and 7-day non perishable quantities were observed to be present in the inside and outside refrigerators and pantry, in compliance at this time.

Observed buildings and grounds in good repair. Exterior fence in good repair with working gate, outside seating for resident use, shaded area, and no health and safety concerns observed outside.

Observed central stored medications locked, unexpired, labeled, and properly stored. Four of four medications counted were accurate to Centrally Stored Log, Medications Administration Records, and PRN logs.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit. An exit interview was conducted with Lesley Pinola, Nataley Martinez, and Brandi Vargas via telephone conference. A copy of this report was provided via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the 809 and appeal rights were received. Lesley is print out the report and fax a signed copy to LPA at 916-263-4744 or email to LPA Ashley Boothe at ashley.boothe@dss.ca.gov.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2021

LIC809 (FAS) - (06/04)

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