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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392790075
Report Date: 09/03/2021
Date Signed: 09/03/2021 03:31:13 PM

Document Has Been Signed on 09/03/2021 03:31 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:HAYNES BOARD AND CAREFACILITY NUMBER:
392790075
ADMINISTRATOR:PARKER, CHERYLFACILITY TYPE:
735
ADDRESS:17201 N. TULLY ROADTELEPHONE:
(209) 727-5834
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 30CENSUS: 21DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Sandra Haynes, AdministratorTIME COMPLETED:
11:45 AM
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On 09/03/2021 at 8:15am, Licensing Program Analyst (LPA) T. White spoke with Administrator, Sandra Haynes regarding facility risk assessment questions. Administrator confirmed no staff or clients have experienced symptoms within the last 10 days. At 9:50am, LPA T. White arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Administrator, Sandra Haynes and Cheryl Parker. LPA explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 30 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 70 degree Fahrenheit. LPA observed hot water temperature measured at 117 and 106.9.LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods.

Fire extinguisher was last serviced on 06/29/2021. LPA observed mitigation plan completed. First aid kit observed to be complete. Emergency Disaster Plan completed on 08/31/2021.

- LPA observed cleaning supplies located in common area accessible to clients in care.

Report continues on 809C.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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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Document Has Been Signed on 09/03/2021 03:31 PM - It Cannot Be Edited


Created By: Treana White On 09/03/2021 at 11:03 AM
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: HAYNES BOARD AND CARE
FACILITY NUMBER: 392790075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 80087(g). LPA observed unlocked cleaning supplies accessible to clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2021
Plan of Correction
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Administrator removed cleaning supplies and locked it away. Deficiency cleared during inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2021


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: HAYNES BOARD AND CARE
FACILITY NUMBER: 392790075
VISIT DATE: 09/03/2021
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The following forms to be updated and submitted to CCLD by 09/10/2021:
LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610 Emergency Disaster Plan

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Administrator. A copy of report and appeal rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
LIC809 (FAS) - (06/04)
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