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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700332
Report Date: 03/23/2021
Date Signed: 03/23/2021 11:36:50 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:A PLACE CALLED HOME IIFACILITY NUMBER:
392700332
ADMINISTRATOR:SIMONE A PIERRE JEROMEFACILITY TYPE:
740
ADDRESS:25820 MAGNOLIA AVETELEPHONE:
(209) 986-3949
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY:11CENSUS: 6DATE:
03/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Lesley PinolaTIME COMPLETED:
11:30 AM
NARRATIVE
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On 3/23/2021 at 11am Licensing Program Analyst (LPA) Ashley Boothe contacted Licensee Lesley Pinola A physical visit was not conducted in that the Department is not conducting visits due to COVID-19. Current Census 6.

On 2/5/2021 LPA requested resident records for Resident one (R1). On 3/18/2021 LPA requested resident records for R1 and Resident two (R2). LPA secured requested documents for R2. Licensee stated during interview R1's records were not available for LPA review. Licensee stated R1 moved out of the facility and went on hospice and R1's records were accidentally disposed of during spring cleaning. Interview with R1's Power of Attorney (POA) stated R1 moved into the facility in 1/2021, was put on Hospice in 1/2021 and transferred to another licensed facility in 1/2021.

Deficiencies being cited per Title 22 California Code of Regulations. Exit interview was conducted with Lesley. Copy of the report was sent to via e-mail with a "read receipt" to verify the LIC 809,LIC 809D and Appeal Rights were received. Lesley is to print out the report and fax signed copies to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2021
Section Cited

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87506 Resident Records(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.
This requirement is not met as evidence by:
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Based on observation, records review, and interview the Licensee did not retain R1's admitted in 1/2021 resident's records. The Licnesee stated they were accidentally disposed of during spring cleaning which poses a potential health and safety risk to residnets 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2021
LIC809 (FAS) - (06/04)
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