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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700332
Report Date: 02/12/2021
Date Signed: 02/16/2021 10:04:18 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: 9DATE:
02/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Martha ArreguinsTIME COMPLETED:
12:30 PM
NARRATIVE
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Unannounced case management visit made out to this facility on 02/12/2021 by LPA Yang, IB Investigator Jorge Martinez and Special Agent Melisa Vega and was met by the Administrator designee Martha Arreguins who was interviewed. This LPA requested that Mrs. Areguins contacted the Licensee/Administrator Lesley Pinela to inform her that CCL was present at this time. Mrs. Arreguins stated that the Administrator Lesley Pinela was out of town at this time and would need an hour or an hour and a half to arrive at this facility. This LPA informed Mrs. Arreguins to tell her over the phone that we would wait for Mrs. Pinela. Mrs. Pinela agreed and stated that she was on her way to this facility.
Current census was 9 residents at this time of which (6) were on hospice, (2) were diagnosed with dementia, and (3) deemed to be bedridden at this time as stated by the facility designee Martha Arreguins.
The purpose of this visit was to conduct a wellness check on the residents and make sure that proper care and supervision was being provided at all times. In addition, This is to clear POCs from complaint/audit findings on 11/06/2020. Title 22 regulations: HSC 1569.652 is still outstanding and not cleared.

IB Investigator Martinez was able to speak and interact with the residents at this time.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 rules and regulations, Health and Safety Code.

Civil penalties of $100.00 per day, per violation, have been accruing since 11/17/20 for the HSC 1569.652 citation. Civil penalties shall be assessed during today's visit for the period of 12/08/2020 to 01/08/2021 in the amount of $3000.00. Civil penalties are still accruing from this visit date, 02/12/2021, until the violation is corrected.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
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: 02/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/12/2021
Section Cited

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1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. This requirement was not met as evidenced by: The
lack of an admissions agreement for R1, missing documents to support extra care and information regarding life expectancy of six
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month or less. This posed a potential health and safety risk.
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purchased at Costco by the POC date 02/12/2021.

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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2021
LIC809 (FAS) - (06/04)
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