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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700332
Report Date: 03/09/2021
Date Signed: 03/09/2021 06:23:37 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 IIFACILITY NUMBER:
392700332
ADMINISTRATOR:SIMONE A PIERRE JEROMEFACILITY TYPE:
740
ADDRESS:25820 MAGNOLIA AVETELEPHONE:
(209) 986-3949
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY:11CENSUS: DATE:
03/09/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Angela ChicasTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Boothe, conducted an unannounced health and safety visit on 3/9/2021 with facility staff one (S1). At 10:00 am LPA arrived and called Licensee Lesley Pinola who was unable to come to the facility. As of today, current census is 7 residents. The facility 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. 1 of 1 staff observed with criminal record clearance and associated in the Licensing Information System.

LPA identified the purpose of the visit and at 10:40am S1 allowed LPA entry to the facility and accompanied LPA on the facility tour. S1 screened LPA for COVID precautionary measures including temperature check and CDC updated COVID questionnaire. LPA observed two visitors enter the facility during the visit who were also screened. All staff and visitors observed wearing masks. S1 stated staff and residents are monitored twice daily at 10am and 3pm. COVID precautionary signs for social distancing were observed in common areas.

Observed residents in the living room and bedrooms. LPA provided technical assistance to move two recliners in living room apart to comply with social distancing. LPA and S1 observed hot water steam from the tap and measured the hot water in the kitchen faucet to be at 131.9 *F, 144.8 *F and 93.9 *F in restroom one, 123.3 *F and 137.3*F in restroom two, and 143.7 *F in restroom three outside of regulatory range of 105 *F and 120 *F. S1 stated she would have it fixed. Restrooms observed with grab bars and non slip mats. One of three restrooms observed without a hand washing sign.

Observed chemicals locked in the laundry room. S1 stated caregivers clean the facility twice daily and use disinfectant bleach.

Continued on 809 C. Page 1 of 3.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: 03/09/2021
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Continued from 809. Page 2 of 3.

At 11:23am observed expired coffee creamer, crescent rolls, and brown rotten lettuce in the refrigerator. S1 immediately disposed of expired foods and LPA provided technical assistance to go through the rest of the food supply to ensure all expired foods are removed. Observed ample food supply of 7-day non perishables and 2-day perishables in the kitchen refrigerator, garage refrigerator, and pantry.

Observed 3 resident records, medication administration records and centrally store medications log to be in compliance at this time. Medications were observed locked, properly stored, properly labeled and unexpired in compliance at this time.

Deficiencies were observed and cited pursuant to Title 22 rules and regulations, Health and Safety Codes. An exit interview was with S1 at the facility at 11:45am. An exit interview was conducted with Lesley Pinola via telephone conference at 6:05pm. A copy of this report was provided to Lesley via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the 809, 809 D 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 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: 03/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 03/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2021
Section Cited

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87303 Maintenance and Operation (e) Faucets...(2)...shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105' F and not more than 120 *F.
This requirement is not met as evidenced by
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Based on observation the licensee did not maintain hot water temperature at the kitchen faucet measured at 131.9 *F, 144.8 *F and 93.9 *F in restroom one, 123.3 *F and 137.3*F in restroom two, and 143.7 *F in restroom three outside of regulatory range of 105 *F and 120 *F outside of regulatory range of 105 *F and 120 *F. which poses an immediate health and safety risk to residents in care.
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Type B
03/19/2021
Section Cited

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87555 General Food Service Requirements (b)The following food service requirements shall apply: (8) All food shall be of good quality. accepted, used or retained.
This requirement is not met as evidence by:
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Based on observation the licensee did not ensure all food was unexpired and not rotten which poses a potential health and safety risk to residents 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: 03/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3