<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700787
Report Date: 10/26/2021
Date Signed: 10/26/2021 04:48:41 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/26/2021 04:48 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:LIBBIE CARE HOMEFACILITY NUMBER:
392700787
ADMINISTRATOR:RAM, AVINESHFACILITY TYPE:
735
ADDRESS:558 E EDISON STTELEPHONE:
(209) 824-5993
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 5CENSUS: 3DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Avinesh RamTIME COMPLETED:
03:30 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
Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced annual/random visit on this date. LPA met with Avinesh and explained the purpose of the visit.

LPA with Staff inspected physical plant including but not limited to kitchen, bedrooms, bathrooms, living and dining room area. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 116.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Carbon dioxide monitor present.
LPA observed centrally stored medications locked inside the medication cabinet.

LPA with the assistance of Administrator reviewed and compared resident medication vs. resident medication logs. LPA, Staff and Administrator reviewed 3 resident and 2 staff files, including criminal record clearances. During the file review the physician's report for R1 was not in the file. All staff today are Fingerprint cleared and associated to the facility. First aid kit was checked and is complete.

Per California Code of Regulations, Title 22 Division 6, Chapter 8 and Health and Safety Code, deficiencies were cited on the 809D attached during this visit. Exit interview held and a report given at the conclusion of the visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/26/2021 04:48 PM - It Cannot Be Edited


Created By: Albert Johnson On 10/26/2021 at 02:01 PM
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: LIBBIE CARE HOME
FACILITY NUMBER: 392700787

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2021
Section Cited
CCR
80069

1
2
3
4
5
6
7
(b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.(1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.
1
2
3
4
5
6
7
Licensee shall submit a current copy of R1's LIC 602 indicating a review of R1's care plan and TB test is completed by POC due date.

In addition submit a letter of audit outcome including if any refunds due with proof of refund amounts due to responsible parties by 10/27/21.

8
9
10
11
12
13
14
This requirement is not met as evidenced by: Records reviewed R1 does not have a LIC 602 on file with a current TB test .

This violation poses an immediate health, and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2