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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392790075
Report Date: 10/12/2022
Date Signed: 10/14/2022 09:20:29 AM

Document Has Been Signed on 10/14/2022 09:20 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
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:
10/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Sandra Andrews, LicenseeTIME COMPLETED:
12:15 PM
NARRATIVE
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On 10/12/2022, LPA R. Campbell and Michael Bilger arrived to facility at approximately 12:00 pm and met with Sandra Andrews, Licensee. LPA R. Campbell explained the purpose of the visit for case management. LPA observed a clean and sanitary facility and staff followed covid precautions.

During a previous incident on 07/17/22, employees(S2 and S3) at The Haynes Facility were found to have not had updated pool safety training certificates per regulatory requirements (80065(e)(2) when residents were in the pool being supervised. Staff provided the Corrective Action Plan and proof that all staff had updated pool safety training certificates during today's visit.

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

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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 10/14/2022 09:20 AM - It Cannot Be Edited


Created By: Renee Campbell On 10/12/2022 at 10:15 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: 10/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2022
Section Cited
CCR
80065(e)(2)

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80065 (e)(2)The licensee shall provide for direct supervision... during participation in.. potentially dangerous activities...(2) Adults who supervise while clients are using a pool...shall have a valid water safety certificate.
This requirement was not met as evidenced by
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Licensee will provide proof that appropriate staff have pool safety training certificates.

Licensee provided POC during case management visit.
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Based on observation, interview and record review, the license did not ensure all staff supervising residents were certified in pool safety.
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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:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022


LIC809 (FAS) - (06/04)
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