392701008-7-28-2021-27-AS-ABOE-C5CTDA-20210728143801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701008
Report Date: 07/28/2021
Date Signed: 07/28/2021 02:38:21 PM

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:	PLACE CALLED HOME		FACILITY NUMBER:	392701008
ADMINISTRATOR:	VARGAS, BRANDI		FACILITY TYPE:	740
ADDRESS:	25820 MAGNOLIA AVE		TELEPHONE:	(714) 948-0381
CITY:	ESCALON	STATE: CA	ZIP CODE:	95320
CAPACITY:	11	CENSUS: 10	DATE:	07/28/2021
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Brandi Vargas		TIME COMPLETED:	02:50 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	On 7/28/2021 Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Post Licensing Inspection. LPA contacted Licensee for COVID questionnaire and was unable to conduct screening prior to today's visit. Staff one (S1) and LPA COVID screened upon entry to the facility. LPA was allowed entry into the facility that is licensed to serve a total capacity of 11 residents. LPA toured with S1, S2, and S3 until Administrator (ADM)Brandi Vargas arrived. Today's census is 10 of which 5 are Hospice. Four of four staff observed on site with criminal record clearance in Licensing Information System. LPA observed administrator Certificate expires on 9/1/2022. Four of ten residents moved to the facility on 7/23/2021 due to transfer from another facility undergoing emergency repairs. LPA interacted with a random number of residents during this visit and observed residents. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, laundry room, garage, restrooms, bedrooms, and common living areas. LPA observed staff cleaning and disinfecting surfaces. LPA observed missing tile on corner of kitchen island, broken chair outside, extra items stored in the garage, patio railing unsecured and wobbly not in good repair, and uncoiled hose in areas resident have access to. The temperature inside the facility was measured at 75F which is within the required range of 68F and 85F, or in areas of extreme heat the maximum shall be 30F less than the outside temperature. The hot water was measured at 154.6F in kitchen and 154.4F in staff restroom with no hot water signs posted above regulatory range of more than 125F. The hot water was measured at and 103.3F, 103.5 F, 104.2 F, and 108.9 F. Three of four taps in resident restrooms observed less than regulatory range of not less than 105F and not more than 120*F. S1 contacted maintenance staff to come adjust during LPA's visit and regulated water temperature to be within regulatory range during today's visit. Continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

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 12

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PLACE CALLED HOME	FACILITY NUMBER: 392701008
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87618(b)(3)(B)

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in that there was no "Oxygen in use" signs posted while R1 observed using oxygen in their room which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/04/2021
	Plan of Correction
1 2 3 4	The licensee agrees to submit proof of signs posted to LPA by POC 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: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC809 (FAS) - (06/04)

Page: 2 of 12

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PLACE CALLED HOME	FACILITY NUMBER: 392701008
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in that there is missing tile on corner of kitchen island, broken chair outside, extra items stored in the garage, patio railing unsecured and wobbly not in good repair, and uncoiled hose in areas resident have access to which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/04/2021
	Plan of Correction
1 2 3 4	The licensee agrees to schedule repair or replacement of the items listed above and submit to LPA written declartation to LPA on when repairs and replacement will be completed by POC 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: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC809 (FAS) - (06/04)

Page: 9 of 12

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PLACE CALLED HOME	FACILITY NUMBER: 392701008
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in he hot water was measured at 154.6F in kitchen and 154.4F in staff restroom with no hot water signs posted above regulatory range of more than 125F. The hot water was measured at and 103.3F, 103.5 F, 104.2 F, and 108.9 F. Three of four taps in resident restrooms observed less than regulatory range of not less than 105F and not more than 120*F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/29/2021
	Plan of Correction
1 2 3 4	Hot water adjusted during today's visit. The licensee agrees to submit a declaration to maintain compliance with this regulation at all times to LPA by POC due date.

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in that four of ten residnet's centrally stored medications were stored in four tupperwares in the unlocked staff office. ADM stated they were for the residents moved in on 7/23/2021 and which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/29/2021
	Plan of Correction
1 2 3 4	Medications secured during today's visit. The licensee agrees to submit a declaration to maintain compliance with this regulation at all times to LPA by POC 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: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC809 (FAS) - (06/04)

Page: 10 of 12

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PLACE CALLED HOME	FACILITY NUMBER: 392701008
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(5)

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed.. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in that R1administered medication one (M1) take 1 tablet by mouth every day in the morning per physicians' orders starting on 7/21/2021. MAR's show no administrations of M1 per order and dosage signed off starting 7/21/2021. MAR signed of administered M1 1/2 tablet by mouth ever day signed off on MAR from 7/13/2021 to current by S1. S1 stated R1 wanted to continue M1 as previously dosed, not as updated physician's order on 7/21/2021. No record of documented notification to physician which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/29/2021
	Plan of Correction
1 2 3 4	The Licensee agrees to submit a written declartion to maintain compliance with this regulation at all times to LPA by POC 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: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC809 (FAS) - (06/04)

Page: 11 of 12

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PLACE CALLED HOME	FACILITY NUMBER: 392701008
	VISIT DATE: 07/28/2021

NARRATIVE

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LPA observed R1's room with no "Oxygen in use" signs posted, R1 observed using oxygen. LPA observed four of ten resident's centrally stored medications stored in four tupperwares in the unlocked staff office, cleaning supplies stored in unlocked laundry room accessible to residents. S2 locked the laundry room and ADM stated they were for the residents moved in on 7/23/2021 and ADM moved medications to locked medications cart and stated S1 was clearing space in the bottom of the medications cart because it did not all fit before, medications secured during today's visit. The first aid kit was found unopened in compliance containing at least the following: a current edition of an approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

LPA observed one of one controlled medications count matched PRN and centrally stored. One of two Medication Administration Record (MAR) not documented medication administered as physician's orders. R1 administered medication one (M1) take 1 tablet by mouth every day in the morning per physicians' orders starting on 7/21/2021. MAR's show no administrations of M1 per order and dosage signed off starting 7/21/2021. MAR signed of administered M1 1/2 tablet by mouth ever day signed off on MAR from 7/13/2021 to current. S1 stated R1 wanted to continue M1 as previously dosed, not as updated physician's order on 7/21/2021. No record of documented notification to physician.

LPA observed fire extinguisher purchased on 3/15/2021, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed one expired gram cracker and jiffy mix in pantry, S1 disposed of it immediately.

LPA reviewed 6 of 10 resident and 4 staff files. LPA was unable to review staff training records during todays visit. S3 and ADM stated the licensee moved them and they were not found during the visit. LPA requested all staff training records and LIC 500 to be submitted to the Department by 8/4/2021 for LPA review.

Per California Code of Regulations (CCRs) - Title 22, Division 6, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation and any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC809 (FAS) - (06/04)

Page: 12 of 12