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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701198
Report Date: 11/17/2022
Date Signed: 11/17/2022 01:08:19 PM

Document Has Been Signed on 11/17/2022 01:08 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:BRENDA'S PLACEFACILITY NUMBER:
392701198
ADMINISTRATOR:MCCARTHY, BRENDAFACILITY TYPE:
740
ADDRESS:408 VALDAPENA COURTTELEPHONE:
(209) 403-2944
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY: 6CENSUS: 3DATE:
11/17/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Susan BristowTIME COMPLETED:
01:30 PM
NARRATIVE
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On 11/17/22 at 10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a post licensing inspection. LPA Jensen met with care provider Susan Bristow and explained the purpose of today's visit. The Licensee, Administrator and designee where not available for the inspection.

LPA Jensen toured the physical plant and the grounds. The facility was observed to be clean and free of odor. LPA Jensen observed the facility to be adequately furnished and have adequate lighting. The knives were observed to locked and inaccessible to residents in care. The medications, toxins and sharp objects were observed to be locked and inaccessible to residents in care. The fire extinguisher was installed in May of 2022 and is in compliance. The grounds were observed to be well maintained and free of debris. There are no obstructions observed on any pathways. There are no bodies of water on the grounds. The water temperature in the bathroom was measured at 103.5 degrees which falls outside of the required regulatory range of 105-120 degrees.

LPA Jensen observed a 7 day supply of perishable food and 2 day supply of non-perishable food on hand.
LPA Jensen interviewed a family member of 1 resident and interacted with 3 of 3 residents. LPA Jensen reviewed the Medication Administration Record and observed missing entries on 3 of 3 resident records. The care staff working with LPA Jensen did not have access to staff files therefore they were not reviewed.

The infection control tool was used during the course of this inspection and technical assistance is being provided.

Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6. Failure to correct deficiencies may result in civil penalty assessment.

An exit interview was conducted and a copy of this report and appeal rights was given to Susan Bristow.




SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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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Document Has Been Signed on 11/17/2022 01:08 PM - It Cannot Be Edited


Created By: Maja Jensen On 11/17/2022 at 12:32 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: BRENDA'S PLACE
FACILITY NUMBER: 392701198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's measurement of the bathroom water tempertaure witrh a reading of 103.5 degrees Fahrenheit, the licensee did not comply with the section cited above in 1 out of 1 count which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2022
Plan of Correction
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Licensee agrees to adjust the hot water temperature and maintain a water temperature reading log that contains readings taken at least once a month or more. The Licensee agrees to send a photo of the water tenmperature reading and the log created to maja.jensen@dss.ca.gov by the Plan of Correction due date.
Type B
Section Cited
CCR
87465(c)(2)

Incedental Medical and Dental Care
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(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onLPA Jensen's Medication Record Review], the licensee did not comply with the section cited above in 3 out of 3 resdient records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2022
Plan of Correction
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Licensee agrees to conduct in-service training on the proper documentation of medication adminsitration records and will email LPA Jensen evidence that the training has occured, who was in attendance and the information covered by the Plan of Correction 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:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
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