392701008-11-4-2021-27-AS-ABOE-C8FRFY-20211104125956

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701008
Report Date: 11/04/2021
Date Signed: 11/04/2021 01:00:09 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:	11/04/2021
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Nataley Martinez		TIME COMPLETED:	01:15 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 11/4/2021 at 10:10am, Licensing Program Analyst (LPA) Ashley Boothe, arrived unannounced to conduct a Health and Safety Visit. Prior to today's visit LPA contacted Licensee Nataley Martinez for COVID screening who confirmed no staff or residents have shown symptoms in the past 10 days. LPA COVID screening upon arrival and explained the purpose of today’s inspection. Current Census is 10 of which 3 are Hospice. Brandi Vargas Administrator accompanied LPA on facility tour during today's visit. Licensee arrived shortly after LPA's arrival. LPA observed three of four staff on site with criminal record clearance associated in Licensing Information System. Staff one (S1) stated they started working at the two to three weeks ago and Administrator stated Licensee is using Guardian to associate staff. LPA observed Guardian S1 "in process" without active criminal record clearance. LPA interacted with a random number of clients during this visit and observed clients. The physical plant was toured inside and outside to ensure the safety of the clients. LPA observed kitchen, garage, restrooms, bedrooms, and common living areas to be clean in good repair. LPA observed oxygen tanks in the garage not in use. Administrator stated they have requested pick up but agency has not come and has previously agreed to come before Monday to remove from property. LPA observed toxins, knives, centrally store medications stored inaccessible to clients. The temperature inside the facility was measured at 69F 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 between 107F and 119F within regulatory range of not less than 105F and not more than 120F. 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: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PLACE CALLED HOME	FACILITY NUMBER: 392701008
	VISIT DATE: 11/04/2021

NARRATIVE

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Continued from 809.

LPA observed fire extinguisher last 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 COVID precautionary measures and signs for universal precautions are posted in common areas. Restrooms stocked with hand soap, touchless covered trash cans and posted hand washing signs but no paper towels. The first aid kit was found 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 medications for three residents in care. Resident One (R1) medications documented on MAR's but no Centrally Stored Medications log as resident moved in recently and Administrator stated they had not created it yet. R1 medications stored with unlabeled over the counter medications without physician's order for medications. Administrator stated family was coming to pick up the medications today to not be stored at the facility.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, 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 provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

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
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: 11/04/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/09/2021 Section Cited	1 2 3 4 5 6 7	Incidental Medical and Dental (h)The following requirements shall apply to medications which are centrally stored:(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year. This requirement not met as evidence by:
	8 9 10 11 12 13 14	Based on observation, interview and records review the licensee did not comply with the section cited above in that R1's medication not documented Centrally Stored Medications as resident moved in recently and Administrator stated they had not created it yet which poses a potential health, safety, and personal rights risks 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

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: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC809 (FAS) - (06/04)

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