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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392790075
Report Date: 09/19/2022
Date Signed: 09/19/2022 12:20:54 PM

Document Has Been Signed on 09/19/2022 12:20 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: 20DATE:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Sandra Haynes - AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace arrived unannounced to conduct a Required 1-year Annual Inspection Visit. LPA met with Administrator and confirmed no staff or clients have experienced COVID symptoms within the last 10 days. LPA explained the purpose of today’s inspection to Administrator. LPA was allowed entry into the facility that is licensed to serve a total capacity of 30 ambulatory clients.

LPA and administrator 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 The hot water measured 111.0*F in kitchen sink which is within the required range of 105-120*F. 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 non-perishable and 2 day perishables foods. LPA observed cleaning supplies locked up in linen closet inaccessible to clients in care. Well water checked for bacterial analysis on 8/16/2022.

Fire extinguishers were last serviced on 06/20/2022. Facility is conducting quarterly fire drills, last one conducted 7/1/2022. LPA observed mitigation plan completed. First aid kit observed to be complete. Emergency Disaster Plan completed on 08/31/2021. LPA observed all exits to have alarms and an unlocked exit in the backyard. There is a pool which is empty at this time, gated is locked.

LPA reviewed 6 of 20 resident records. LPA reviewed 4 staff records and all have health screen and TB results. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed current first aid certificates and are current. Administrator Certificate expired 1/6/2022.

LPA Wallace completed infection control domain and observed no issues or concerns.



One deficiency was observed or cited from the California Code of Regulations, Title 22.

Exit interview conducted with Administrator. A copy of reports and appeal rights given to administrator.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 09/19/2022
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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2022 12:20 PM - It Cannot Be Edited


Created By: Ruth Wallace On 09/19/2022 at 12:09 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: HAYNES BOARD AND CARE
FACILITY NUMBER: 392790075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

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 administrator certificate expired 1/6/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2022
Plan of Correction
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Licensee submitted current temporary administrator certticate to LPA Wallace during today's visit. No further action required.
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:Stephen Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022


LIC809 (FAS) - (06/04)
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