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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700473
Report Date: 02/28/2024
Date Signed: 03/05/2024 01:48:22 PM


Document Has Been Signed on 03/05/2024 01:48 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTECFACILITY NUMBER:
392700473
ADMINISTRATOR:SHERYL BRAVOFACILITY TYPE:
740
ADDRESS:430 NORTH UNION RDTELEPHONE:
(209) 823-0164
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY:84CENSUS: 52DATE:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Karen RiggsTIME COMPLETED:
04:30 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 02/28/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated representative Karen Riggs who was briefly interviewed. It was learned that there were residents under the care of hospice at this time while other residents were receiving services through home health as well.
This facility does have a hospice waiver approved for (10) residents of which there are (4) present at this time.
It was learned that there weren't any residents deemed to be bedridden at this time.
Current census was 52 residents.
A tour of this facility was conducted at this time.
Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Sheryl Bravo.
Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time.
A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication rooms, located on each floor, were reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the facility designated medication technicians at this time. The medication carts were observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restroom was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. It was learned that there were several different floor plans for residents on the Assisted Living portion of this facility.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC
FACILITY NUMBER: 392700473
VISIT DATE: 02/28/2024
NARRATIVE
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Linen closet, located in the facility laundry area, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
A tour of the Memory Care portion was conducted.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 02/27/2024 by the local fire extinguisher company, Johnson Controls, and in compliance at this time.
First aid kits were observed to be present and contained all of the required components at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted.

A review of (6) facility resident files was conducted and noted on the following LIC 858.
A review of (6) facility personnel files was conducted and noted on the following LIC 859.

The following forms and documents were requested to be updated and submitted into CCL:
  • 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 Codes.

Appeal Rights were printed and a copy was given to the facility designated representative at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/05/2024 01:48 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC
FACILITY NUMBER: 392700473

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the Custodian closet, housing cleaning supplies and chemicals, along with (2) other laundry rooms with posted signs to be locked at all times were unlocked and made accessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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The facility designated representative stated that all staff will be in-serviced, for no less than (1) hour in duration, on the topic for proper storage and maintenance of all cleaning supplies and chemicals. A statement of correction, along with proof of completed training for all facility staff, will be completed and submitted into CCL by the due date.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [6] out of [6] facility personnel files did not contain updated First Aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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The facility representative stated that all facility personnel files will reviewed and any staff missing required First Aid training, and expired First Aid training, will be scheduled to receive and complete updated First Aid training. A statement of correction, along with copies of all facility staff updated First Aid training certifications, 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 KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 03/05/2024 01:48 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC
FACILITY NUMBER: 392700473

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)(5)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [2] out of [6] facility resident files did not have updated annual medical assessments to address any possible changes with a dementia diagnosis which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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The facility representative stated that a review of all resident files diagnosed with dementia will be conducted. Any, and all, resident files which require an updated annual medical assessment will be scheduled with their responsible licensed medical professional to undergo, and receive, an updated annual medical assessment. A statement of correction, along with copies of all updated medical assessments, will be completed and submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 03/05/2024 01:48 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC
FACILITY NUMBER: 392700473

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that several window screens were observed to missing and others were observed to contain holes, tears, or rips in them which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2024
Plan of Correction
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The facility representative stated that a review of the exterior window screens will be conducted. Any, and all, window screens which are missing or contain holes, rips, or tears within them will be repaired/replaced. A statement of correction, along with copies of the receipt for services rendered for the window screen repair/replacements, will be completed and submitted into CCL by the due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [5] out of [6] facility personnel files were missing updated annual training hours which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2024
Plan of Correction
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The facility representative stated that a review of all facility personnel files will be conducted. Any, and all, facility personnel missing required annual training and training hours will be in-serviced to meet the required training topics and training hours requirements. A statement of correction, along with copies of all completed and updated training topics with corresponding training hours, 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 KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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