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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701350
Report Date: 09/30/2024
Date Signed: 10/01/2024 09:24:12 AM

Document Has Been Signed on 10/01/2024 09:24 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:LA HACIENDA CARE MANTECA, LLCFACILITY NUMBER:
392701350
ADMINISTRATOR/
DIRECTOR:		VALLARTA, ANABELEN D.FACILITY TYPE:
740
ADDRESS:597 HACIENDA AVENUETELEPHONE:
(510) 709-7078
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 6CENSUS: 3DATE:
09/30/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Tomas Bello and Anabelen VallartaTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Unannounced Post Licensing visit made out to this facility on 09/30/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, Anabelen Vallarta, who was briefly interviewed at this time.
Current census was 3 residents.
It was learned that there was (1) resident under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (2) residents under the care of hospice at any given time.
It was learned that this facility has a program to be able to accept and retain dementia residents at any given time. It was learned that there were (3) residents diagnosed with dementia at this time.
It was learned that there was (1) resident receiving services through home health at this time.
Tour of this facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Linen closet, located in facility hallway closet, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time.
Kitchen area was toured.
Kitchen drawers and cabinets were opened and reviewed.
Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured.
Additional food storage units located in the garage area were observed to be present and functional at this time.
Laundry area, located in the room next to the garage, was toured.
Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Administrator certificate, # 6068533740, for Anabelen Vallarta was observed to have an expiration date of
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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: LA HACIENDA CARE MANTECA, LLC
FACILITY NUMBER: 392701350
VISIT DATE: 09/30/2024
NARRATIVE
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04/16/2026 and in compliance at this time.
Medication cabinets, located in the facility hallway closet , was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in the medication closet, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguishers were located throughout this facility and observed to have been purchased at the local Costco, with the receipt with date of annual purchase attached on 06/17/2024, and in compliance at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.
A review of (5) facility personnel records was conducted on the LIC 859.
A review of (3) facility resident records was conducted on the LIC 858.

The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

LIC 308
LIC 400
LIC 500
LIC 610

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 copy was given to the facility designated Administrator at this time.
Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/01/2024 09:24 AM - It Cannot Be Edited


Created By: Charlie Yang On 09/30/2024 at 12:34 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LA HACIENDA CARE MANTECA, LLC
FACILITY NUMBER: 392701350

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a record review, the licensee did not comply with the section cited above in [2] out of [5] facility personnel were not properly cleared for TB which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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The facility designated Administrator stated that all facility staff providing care and supervision to the residents will be scheduled with their licensed medical professional to undergo and receive clearance for TB. A statement of correction, along with a copy of the cleared TB tests, will be completed and submitted into CCL by the due date of 10/01/2024.

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:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/01/2024 09:24 AM - It Cannot Be Edited


Created By: Charlie Yang On 09/30/2024 at 12:34 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LA HACIENDA CARE MANTECA, LLC
FACILITY NUMBER: 392701350

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87208(d)
Plan of Operation
(d) A licensee who accepts or retains bedridden persons shall include additional information in the plan of operation as specified in Section 87606(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [3] facility residents were deemed to be bedridden and this facility does not have an updated Plan of Operation to address the rules and policies in order to accept and retain bedridden residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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The facility designated Administrator stated that an updated Plan of Operation will be completed and submitted into CCL addressing the rules and policies in order to accept and retain bedridden residents at any given time. A statement, along with this completed and updated Plan of Operation, will be completed and submitted into CCL by the due date of 10/01/2024.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a record review, the licensee did not comply with the section cited above in [2] out of [5] facility personnel were missing updated certified First Aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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The facility designated Administrator stated that all facility personnel providing care and supervision to the residents will be scheduled to undergo and complete First Aid training. A statement of correction, along with copies of updated First Aid training certificates/cards, will be completed and submitted into CCL by the due date of 10/01/2024.
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:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
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