392701103-11-28-2023-27-AS-CYAG-CXZP32-20231128095648

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701103
Report Date: 11/27/2023
Date Signed: 11/28/2023 09:56:53 AM

Document Has Been Signed on 11/28/2023 09:56 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	PEDROSE HOME CARE		FACILITY NUMBER:	392701103
ADMINISTRATOR:	MABUNGA, JOYCE MAE		FACILITY TYPE:	740
ADDRESS:	1098 COLLINS ST		TELEPHONE:	(925) 998-1927
CITY:	MANTECA	STATE: CA	ZIP CODE:	95337
CAPACITY:	6	CENSUS: 2	DATE:	11/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Pedro Pancho		TIME COMPLETED:	02:00 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	Announced Annual visit made out to this facility on 11/27/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Pedro Pancho, at this time. A brief interview was conducted with the facility designated Administrator at this time. It was learned that this facility was licensed for a total of (6) residents, of which, all (6) could be nonambulatory. This facility is licensed to be able to retain (1) bedridden resident with a hospice waiver approved for (6) residents. Current census was 2 residents. There was (1) resident under the care of hospice at this time according to statements made by the facility designated Administrator. Tour of this facility was conducted. A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time. Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time. A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times. Medication cabinet, located in the facility entry way, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility designated Administrator at this time. A review of the facility Medication Administration Record and dispensing log was conducted. Medication cabinet was observed to be locked and made inaccessible to the residents at this time. Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PEDROSE HOME CARE	FACILITY NUMBER: 392701103
	VISIT DATE: 11/27/2023

NARRATIVE

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A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted. Grab bars and non skid mats were observed to be present and in compliance at this time.
Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Laundry room was observed to be locked with the detergents, soaps, and bleach products were properly stored at this time. It was learned that all cleaning and laundry supplies were separately locked and made inaccessible to the residents at all times.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguisher was observed to be placed in the kitchen area and was just recently purchased and found to be in compliance at this time.
A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.

A review of (2) facility resident files was conducted and noted on the LIC 858.
A review of (3) facility staff files was conducted and noted on the LIC 859.

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

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/28/2023 09:56 AM - It Cannot Be Edited

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: PEDROSE HOME CARE	FACILITY NUMBER: 392701103
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(c)(1)(C)1

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (C) An Infection Control Training Plan. 1. Initial training requirements for new facility staff shall be addressed in the plan, with training to be provided by the Infection Control Lead before staff works independently with residents. 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 since facility staff did not have documented initial training with corresponding required hours which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/03/2024
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all facility staff will undergo, and complete, the required hours of initial training and have it all documented within the corresponding staff records. A statement of correction, along with copies of all required initial hours of training, will be submitted into CCL by the due date.

Type B

Section Cited

CCR

87470(c)(1)(C)2

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (C) An Infection Control Training Plan. 2. Ongoing training requirements for all facility staff shall be addressed by the plan, with training to be provided by the Infection Control Lead. 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 since facility staff did not have documented ongoing/annual training with corresponding required hours which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/03/2024
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all facility staff will undergo, and complete, the required hours of ongoing/annual training and have it all documented within the corresponding staff records. A statement of correction, along with copies of all required ongoing/annual hours of training, 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	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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