392700473-2-21-2023-27-AS-CYAG-CP9Q97-20230221105748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700473
Report Date: 02/15/2023
Date Signed: 02/21/2023 10:58:12 AM

Document Has Been Signed on 02/21/2023 10:58 AM - 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:	MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC		FACILITY NUMBER:	392700473
ADMINISTRATOR:	SHERYL BRAVO		FACILITY TYPE:	740
ADDRESS:	430 NORTH UNION RD		TELEPHONE:	(209) 823-0164
CITY:	MANTECA	STATE: CA	ZIP CODE:	95337
CAPACITY:	84	CENSUS: 54	DATE:	02/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sheryl Bravo		TIME COMPLETED:	01:00 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	Unannounced annual visit conducted on 02/15/2023 by Licensing Program Analysts (LPAs) Charlie Yang and Kimberly Viarella who requested that the facility designated administrator, Sheryl Bravo, be notified that CCL was present at this time. Brief interview conducted with the facility designated Administrator. It was learned that there 6 hospice residents with 11 in memory care and 2 residents receiving home health. Current census was 54 residents. LPAs toured the facility grounds and observed the following. The dining room and common areas in the buildings were found to have adequate furniture and lighting. There were no trip hazards observed at this time. The kitchen area was inspected and found to be clean with refrigerators and freezers observed to be at the required temperatures. There was an adequate 2 day perishable and 7 day non-perishable food supply observed at this time. Residents do not have access to the kitchen and it is locked when it is not being staffed by the chef and kitchen employees, thus ensuring that sharp knives and other kitchen implements were made inaccessible at all times. A sample of the resident bedrooms were toured and observed to be in order with adequate furniture and lighting. Brief interviews were conducted with the residents. Resident restrooms were toured. The hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees at all times. Grab bars were observed to present and in functional order at this time. Non skid mats were also oberved to be present and in good order at this time. LPAs toured the Medication Room. It was a separate locked room adjacent to the main lobby. Each of the Med Techs on shift have access to the room, its paper logs, and the computerized EMAR system. The medication cabinet for narcotics had a double lock system. Medications were distributed to each resident individually and logged at the point of consumption. While touring the exterior grounds of the facility, LPAs observed a new fence bordering the memory care unit had been installed. A review of the facility perimeter fence, side gates, and exits was conducted.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC	FACILITY NUMBER: 392700473
	VISIT DATE: 02/15/2023

NARRATIVE

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Fire extinguishers, hung throughout this facility, were reviewed to make sure that they were annually inspected and in compliance at this time.

The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

LIC 308

LIC 400

LIC 500

LIC 610

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

The appeal rights were printed and a copy was given to the facility designated Administrator Sheryl Bravo at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/21/2023 10:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC	FACILITY NUMBER: 392700473
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation by this LPA, the licensee did not comply with the section cited above in that the facility perimeter fence was falling down in sections and was in need of repair/replacement which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/22/2023
	Plan of Correction
1 2 3 4	Facility designated personnel stated that a work order will be commissioned and the fallen fence sections of the perimeter will be replaced/repaired as needed. A statement of correction, along with a copy of the work order and photos of the updated fence, will be completed and submitted into CCL by the due date.

Type B

Section Cited

CCR

87303(c)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation by this LPA, the licensee did not comply with the section cited above since windows screens were torn, had holes, or were in need of repair/replacement which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/22/2023
	Plan of Correction
1 2 3 4	Facility designated personnel stated that a work order will be commissioned and the window screens will be replaced/repaired as needed. A statement of correction, along with a copy of the work order, will be completed and submitted into CCL by the due date.

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

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