392700787-4-30-2024-27-AS-CYAG-D4TRR3-20240430131425

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700787
Report Date: 04/29/2024
Date Signed: 04/30/2024 01:14:31 PM

Document Has Been Signed on 04/30/2024 01:14 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:	LIBBIE CARE HOME		FACILITY NUMBER:	392700787
ADMINISTRATOR/ DIRECTOR:	RAM, AVINESH		FACILITY TYPE:	735
ADDRESS:	558 E EDISON ST		TELEPHONE:	(209) 824-5993
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY: 5		CENSUS: 3	DATE:	04/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Avinesh Ram		TIME VISIT/ INSPECTION COMPLETED:	12:30 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 visit made out to this facility on 04/29/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Avinesh Ram. A brief interview was conducted with the facility designated Administrator at this time. This LPA requested that he go ahead and inform the facility Licensee to inform her that CCL was present at this time. This facility was vendorized to accept and retain Level 3 residents from the regional center, Valley Mountain Regional Center, at this time. Current census was 3 residents. It was learned that there weren't any residents under the care of hospice at this time. It was learned that there weren't any residents diagnosed with dementia at this time. A tour of this facility was conducted. Administrator certificate was observed to be present and in compliance at this time for facility designated Licensee/Administrator Renee Tang. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the certificate #6041373735 expiration date of 12/08/2024. Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet and supplies, located in the kitchen area, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator at this time. This medication cabinet was observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Linen closets were observed to contain a sufficient supply of towels, blankets, and linens to meet the needs

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

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: LIBBIE CARE HOME	FACILITY NUMBER: 392700787
	VISIT DATE: 04/29/2024

NARRATIVE

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of the residents at this time.
Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 05/03/2023 by the local fire extinguisher company, Alpha Fire Control, and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.
A review of (3) facility resident records was conducted and noted on the following LIC 858 form.
A review of (2) facility staff records was conducted and noted on the following LIC 859 form.

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 Administrator at this time.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/30/2024 01:14 PM - It Cannot Be Edited

Created By: Charlie Yang On 04/29/2024 at 11:31 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LIBBIE CARE HOME	FACILITY NUMBER: 392700787
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(c)

Building and Grounds

(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. 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 the outdoor backyard area had tall weeds and fallen leaves all over the walkways/pathways which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/06/2024
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that the backyard area will be cleaned and all weeds and fallen leaves will be removed to clear up pathways and areas intended for resident use. A statement of correction, along with photos of the cleared backyard area, will be completed and submitted into CCL by the due date.

Type B

Section Cited

CCR

80070(a)

The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. 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 [3] facility resident records were incomplete missing required forms and documents which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 05/06/2024
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all facility resident records will be updated to contain all required forms and documents. A statement of correction will be completed and copies of all updated forms and documents will be 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

LICENSING EVALUATOR NAME:

Charlie Yang

LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC809 (FAS) - (06/04)

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