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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392790075
Report Date: 08/10/2023
Date Signed: 08/29/2023 01:57:18 PM

Document Has Been Signed on 08/29/2023 01:57 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
SACRAMENTO AC/SC, 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: 19DATE:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Sandra Haynes-Andrews, LicenseeTIME COMPLETED:
03:15 PM
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LPA Renee Campbell and LPA Victoria Brown arrived unannounced to conduct a required annual inspection visit on 08/10/23 at approximately 8:15 am. LPA's Campbell and Brown met with Sandra Haynes-Andrews, Licensee and Cheryl Parker, Licensee and stated the purpose of the visit.

The facility has a capacity of 30 residents but currently maintains a census of 19. At the time LPA's arrived, only 2 of the residents were present and sitting in the living room after breakfast. The rest were at day program. Of the 30 residents, the facility is licensed to have 30 ambulatory residents. Curtains were hung at the windows and were open to let light into the common areas, .

LPA's Campbell and Brown entered the facility through the kitchen. Cabinetry and countertops were found to be in a clean, sanitary and odorless condition. Entering the dining room, LPA's found tables and chairs for residents were set and ready for use by residents. LPA observed required furniture for the living room common area. The licensee lead LPA's through the residential area. Each room had the required furniture and functioning lights. Linens were kept in a chest of drawers in the hallway and was accessible to all residents. Rooms had windows or patio doors that were operable.

Outside of the physical plant, there was a pool in the backyard that was inaccessible and surrounded by a metal fence that was at least 5 feet high. During the visit, the pool was being cleaned as well. During the tour of the facility, LPA Campbell and LPA Brown observed that the carbon monoxide and smoke detector were tested and functioning. The smoke detector was hard wired to the pull alarm. The water temperature was measured in one of the six bathrooms and was found to be 105 degrees Fahrenheit. The toilet, sink and shower were found to be functioning. One bathroom in the men's section had been closed for repairs. The room temperature was kept at 71 degrees Fahrenheit. LPA reviewed the floor plan which mimics the facility sketch.
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: HAYNES BOARD AND CARE
FACILITY NUMBER: 392790075
VISIT DATE: 08/10/2023
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The licensee was observed using a lock to open and close the medicine cabinet and to secure toxins and dangerous chemicals. The washer and dryer were housed in an outdoor shed area. Residents had access to the detergent so that they could do their own laundry.

The licensee guided LPA's to the food pantry. Non-perishable items were stacked on shelves and perishable items were found in the two freezers and refrigerators. There were enough perishables to last the staff and residents two days and there were enough non-perishable foods to last them seven days. LPA Campbell and Brown observed a landline telephone that was kept in the dining room. Of the two fire extinguishers that were inspected, both had been inspected on 06/21/23. Several areas of the home were separated by an elevated entrance.

P&I was reviewed for one resident. The documentation is correct and monies are not commingled.
LPA Renee Campbell and LPA Victoria Brow reviewed 2 of 19 files for residents and 2 of 16 files for staff.
LPA Campbell then interviewed 5 staff who were present and 1 resident who was available. One other resident was unavailable to interview. The most recent fire/disaster drill was completed on 07/17/2023

Upon the file review the following items were discussed to be submitted with any changes annually:

Designation of Facility Responsibility (LIC308), Personnel Report (LIC500), Administrator Certificate Updated
Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies cited. Exit interview held, copy of report given
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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