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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700673
Report Date: 01/03/2023
Date Signed: 01/06/2023 09:57:28 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/06/2023 09:57 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:BUENA VIDA CARE HOME IFACILITY NUMBER:
392700673
ADMINISTRATOR:LADION, PIERRE J.FACILITY TYPE:
735
ADDRESS:10510 SILENT GROVE CTTELEPHONE:
(209) 943-0051
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 4CENSUS: 4DATE:
01/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Norma Diaz TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Kesha Lewis arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by Staff. LPA was screened upon entry for COVID precautions. LPA explained the purpose of the visit to staff. Administrator's Certificate # 6012618735 Expires 06/26/2023

LPA and staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 4 bed facility with a current census of 4. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing noted. Chemicals and medications noted to not be locked to residents in care. LPA observed Insulin in the refrigerator door not locked.

Hot water temperature was measured at 105 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2023
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: BUENA VIDA CARE HOME I
FACILITY NUMBER: 392700673
VISIT DATE: 01/03/2023
NARRATIVE
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LPA observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a COVID -19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.

LPA observed, fire extinguishers inspected on 11/23/2021 and are not in compliance. Current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

LPA reviewed one (1) staff files. There is only one staff at this time. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required.



LPA reviewed two (2) resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place.

Exit interview held with staff and copies of reports left at conclusion of visit.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/06/2023 09:57 AM - It Cannot Be Edited


Created By: Kesha Lewis On 01/03/2023 at 10:21 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BUENA VIDA CARE HOME I
FACILITY NUMBER: 392700673

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/04/2023
Section Cited
CCR
80075(k)(1)

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(k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Administrator shall purchase a lock box for medication that needs to be kept in the refrigartor and send verification to LPA by email. Kesha.Lewis@dss.ca.gov
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This requirement is not met as evidenced by observation LPA observed Insulin in the refrigerator door not locked. This poses an immediate health and safety risk
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Type A
01/04/2023
Section Cited
CCR80020(a)

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80020(a) Fire Clearance. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
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Administrator shall have an appointment set for the fire extinguishers to be serviced by close of business of POC date and send verification to LPA by email. Kesha.Lewis@dss.ca.gov
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This requirement is not met as evidenced by observation and tag on fire extinguishers show they were serviced on 11-23-2021. This poses an immediate health and safety risk
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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 King
LICENSING EVALUATOR NAME:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2023


LIC809 (FAS) - (06/04)
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