392700557-8-10-2023-27-AS-CYAG-CUL7GN-20230810213925

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700557
Report Date: 08/09/2023
Date Signed: 08/10/2023 09:39:57 PM

Document Has Been Signed on 08/10/2023 09:39 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	GELZHEN GUEST HOME LLC		FACILITY NUMBER:	392700557
ADMINISTRATOR:	LAJA, JOY		FACILITY TYPE:	740
ADDRESS:	119 N LINCOLN AVE		TELEPHONE:	(209) 239-5500
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	15	CENSUS: 8	DATE:	08/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Knicole Carbonell and Joy Laja		TIME COMPLETED:	01:30 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 licensing visit made out to this facility on 08/09/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Knicole Carbonell, who was briefly interviewed. This LPA requested that the facility caregiver go ahead and contact the facility designated Administrator, Joy Laja, to inform her that CCL was present at this time. The facility designated Administrator, Joy Laja, arrived thereafter to this facility. A brief interview was conducted with the facility designated Administrator at this time. This facility is licensed to serve and accept up to 15 residents who are deemed to be ambulatory and non ambulatory. This facility is not vendorized to accept and retain any Regional Center residents at this time. Current census was 8 residents. It was learned that there was (1) resident currently on hospice. There were (3) dementia diagnosed residents and (6) residents with bowel/bladder incontinence. Tour of this facility was conducted. Kitchen area was toured. Cabinets and drawers were reviewed. Drawers and cabinets housing cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Drawers containing knives and other cutlery were observed to be locked and made inaccessible to the residents at this time. Food supply was reviewed for 2-day perishable and 7-day nonperishable food quantities at this time. Additional nonperishable food items were observed to be stored in the garage area along with additional refrigerator and freezer units. Dining room, living area, and all other areas designated for resident use were observed to be maintained and observed to be in compliance at this time. A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be present and maintained in compliance at this time. A tour of the resident restrooms was conducted. Shower areas, toilets, and wash basins were reviewed and observed to be functional and in good repair at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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: GELZHEN GUEST HOME LLC	FACILITY NUMBER: 392700557
	VISIT DATE: 08/09/2023

NARRATIVE

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105-120 degrees.
Medication for resident use, located in kitchen cart, was reviewed. Policies and procedures for dispensing, handling, and overall documentation of the resident medications were discussed with the facility designated Administrator at this time.
Fire extinguishers (3) were observed to be placed in the kitchen, dining, and laundry areas were annually inspected on 03/15/2023 from the local fire extinguisher company, Nor Cal Fire Inc, and in compliance at this time.
First aid kit was observed to be present and contained all of the required components at this time.
Linen closet, located in facility hallway, was observed to contain a sufficient supply of blankets, sheets, and towels for resident use.
Laundry area, located adjacent to kitchen area, was observed to be made inaccessible to the residents at this time. Laundry detergents, bleach, and all other cleaning supplies were observed to be stored in cabinets where they were locked and made inaccessible to the residents at this time.
Exterior grounds of this facility was toured. Facility perimeter fence, side gates, and emergency exits were reviewed.
Additional garage space was reviewed and observed to be contain materials and items intended for upkeep and maintenance of this facility.
A review of (4) facility personnel files was conducted.
A review of (5) facility resident files was conducted.

The following forms 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 Administrator 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: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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: GELZHEN GUEST HOME LLC	FACILITY NUMBER: 392700557
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions


	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

Type A

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [2] out of [4] personnel files were missing required documentation of current certified First Aid training which poses/posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that a statement of correction, along with copies of the updated missing first aid certification, 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: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/10/2023 09:39 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GELZHEN GUEST HOME LLC	FACILITY NUMBER: 392700557
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.69(a)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [3] out of [4] personnel files were missing required medication training and verification which poses/posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that a statement of correction, along with copies of the updated medication training and verification forms and documents, will be completed and submitted into CCL by the due date.

Type A

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [2] out of [4] personnel files were missing required documentation of a medical assessment, signed by a physician, made within the last year which poses/posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that a statement of correction, along with copies of the updated missing medical assessment forms and documents, 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: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/10/2023 09:39 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GELZHEN GUEST HOME LLC	FACILITY NUMBER: 392700557
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(c)

Personnel Records

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [3] out of [4] personnel files were missing required training and orientation verification which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that a statement of correction, along with copies of the updated missing training forms and documents, will be completed and submitted into CCL by the due date.

Type B

Section Cited

CCR

87506(a)

Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [4] out of [5] resident files were missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that a statement of correction, along with copies of the updated missing forms and documents, 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: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/10/2023 09:39 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GELZHEN GUEST HOME LLC	FACILITY NUMBER: 392700557
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87625(b)(3)

Managed Incontinence

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that several resident bedrooms and restrooms had strong odors of urine and feces which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that a statement of correction will be completed, along with proof of staff training (for no less than one hour in duration), on the topic of resident incontinence care and the facility's responsibility to keep residents clean and dry. In addition, staff will be further trained to maintain the facility free of odors from incontinence and be submitted into CCL by the due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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