392701198-8-30-2023-27-AS-MJEN-CV7UFE-20230830153236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701198
Report Date: 08/30/2023
Date Signed: 08/30/2023 03:32:51 PM

Document Has Been Signed on 08/30/2023 03:32 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 PLACE		FACILITY NUMBER:	392701198
ADMINISTRATOR:	MCCARTHY, BRENDA		FACILITY TYPE:	740
ADDRESS:	408 VALDAPENA COURT		TELEPHONE:	(209) 403-2944
CITY:	ESCALON	STATE: CA	ZIP CODE:	95320
CAPACITY:	6	CENSUS: 1	DATE:	08/30/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Brenda McCarthy		TIME COMPLETED:	04:45 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 8/30/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue an annual inspection that was commenced on 7/28/23. LPA Jensen met with Licensee Brenda McCarthy and explained the purpose of today's visit. The Administrator holds a current certificate number 6017049740 good through 7/18/24. LPA Jensen toured the grounds and observed the grounds to be well maintained and all pathways were unobstructed. The window screens were observed to be in good repair. The facility is 3 bedroom and 2 1/2 bath. The main entrance to the facility has a sign in sheet and postings for Resident Council, personal rights, and "See Something, Say Something". The interior was adequately furnished and lit. The facility was observed to be sanitary and free of odor. The thermostat was set at 72 degrees Fahrenheit for the comfort of the residents. The facility maintains an adequate supply of linens. All bedrooms are adequately furnished. The bathrooms have grab bars and non-slip mats for the shower/bath. The water temperature in the common bathroom was measured at 113 degrees Fahrenheit and is in compliance. The smoke detector and carbon monoxide detector were observed to be in good working order. There are night lights in the hallway and battery operated lighting is available in every room in case of a power outage. The facility conducts regular fire drills. LPA Jensen observed a first aid kit that was complete. LPA Jensen toured the kitchen. The facility maintains a 2 day supply of perishable food and a 7 day supply of non-perishable food. Knives, medications and toxins are locked and inaccessible to residents in care. LPA Jensen reviewed the medication and observed the Centrally Stored Medication and Destruction Record (CSMDR) to be incomplete. The facility accepted a resident without documenting the medication the resident arrived with. The medication on hand for Resident 1 (R1) was inconsistent with the Medication Administration Record (MAR) and Physician orders. Continued on LIC 809C...

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

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

FACILITY NAME: BRENDA'S PLACE	FACILITY NUMBER: 392701198
	VISIT DATE: 08/30/2023

NARRATIVE

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Continued from LIC 809....
LPA Jensen interviewed the sole resident and sole staff member present at the time of the visit. LPA Jensen reviewed 1 resident file and found it to be complete. LPA Jensen reviewed 1 staff file and determined there was no training records for the staff member maintained on site at the time of the visit.

LPA Jensen requested a current copy of the liability insurance and an LIC 500 to be sent by 9/1/23.

The Inspection Tool was used during the course of this visit. Deficiencies are being cited from California Code of Regulations (CCR) and/or Health and Safety Code (HSC). Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/30/2023 03:32 PM - 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BRENDA'S PLACE	FACILITY NUMBER: 392701198
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(6)

When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Jensen's review of the CSMDR and MAR, the CSMDR was never completed for R1 and the MAR was inconsistent with medications on hand therefore the licensee did not comply with the section cited above residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2023
	Plan of Correction
1 2 3 4	The Licensee agrees to train all staff on medication administration and record keeping through a third party source or outside vendor. The Licensee agrees to schedule the training by 8/31/23 with training completed by 9/30/23 and will email LPA Jensen proof of completion.

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: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 08/30/2023 03:32 PM - 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BRENDA'S PLACE	FACILITY NUMBER: 392701198
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(g)

All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Jensen's review of 1 staff file that did not contain training records, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/01/2023
	Plan of Correction
1 2 3 4	The Licensee agrees to sign an attestation that records will be maintained at the facility and will send the training records for Staff 1 (S1) by email to LPA Jensen by the 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: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC809 (FAS) - (06/04)

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