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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000618
Report Date: 05/12/2023
Date Signed: 05/12/2023 03:36:22 PM

Document Has Been Signed on 05/12/2023 03:36 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:SOLIDUM CARE HOME #8FACILITY NUMBER:
397000618
ADMINISTRATOR:NORMA SOLIDUMFACILITY TYPE:
735
ADDRESS:217 BERNICE AVENUETELEPHONE:
(209) 477-2413
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 5DATE:
05/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lynn Caoli, AdministratorTIME COMPLETED:
03:40 PM
NARRATIVE
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On May 12, 2023 at approximately 10:30am, Licensing Program Analysts Jennifer Fain and Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPAs met with the administrator Lynn Caoli and explained the purpose of the visit.

LPAs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is an Adult Residential Facility with a current census of 5. Facility has 4 bedrooms and 2 bathrooms for resident use. Facility has a dining area off the kitchen and a formal living room. LPAs also conducted the inspection using the CARE tool. Facility currently provides care for 2 ambulatory residents and 3 non ambulatory residents. The facility has central entry point and has implemented screening and sign in procedures at the front door area.

Water temperature reads between the regulation 105*F to 120*F in the bathroom and room temperature reads 70 degrees F, within the regulation 68 - 85 degrees. LPAs observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was serviced May 1, 2023 and the facility has a fire sprinkler system. The facility has an emergency food supply. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed and contained accompanying regulatory required Physician’s orders. First aid kit was observed to have adequate supplies and accessible to staff.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023
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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SOLIDUM CARE HOME #8
FACILITY NUMBER: 397000618
VISIT DATE: 05/12/2023
NARRATIVE
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During this inspection 5 of 5 resident files and 4 of 4 staffing files were reviewed for regulatory compliance. All staff files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances. LPAs completed 2 resident interviews and 2 staff interviews. Resident files reviewed revealed 2 residents over the age of 60 without updated medical assessments and updated functional assessment capabilities form. Additionally, facility does not have a plan of operation updated to reflect care of persons who require assistance will all activities of daily living. Facility does not contain any bodies of water. LPAs observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. LPAs observed facility’s activity calendar. LPAs reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. Facility has 1 resident with bedrails with physician orders in place. LPAs requested an updated copy of LIC 308 and LIC 500.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit and noted on LIC 809D. An exit interview was held and a report was given to Administrator Lynn Caoli. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/12/2023 03:36 PM - It Cannot Be Edited


Created By: Jennifer Fain On 05/12/2023 at 02:13 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: SOLIDUM CARE HOME #8
FACILITY NUMBER: 397000618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80022(e)
Plan of Operation
(e) If the licensee intends to admit or care for one or more clients who rely upon others to perform all activities of daily living, the plan of operation must also include a statement that demonstrates the licensee's ability to care for these clients. The evidence of ability may include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did not comply with the section cited above in that facility retains clients over 60 years of age, and facility's plan of operation does not contain the required regulatory language necessary to care for clients 60 years of age and older, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2023
Plan of Correction
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Licensee will update plan of operation accordingly to comply with Section 80022(e) and submit updated plan of operation section to LPA by POC due date.
Type B
Section Cited
CCR
85068.4(c)(1)
Acceptance and Retention Limitations. (c) When a licensee admits or retains any person 60 years of age or older, the licensee shall ensure that all of the following information is contained in the persons file: (1) Completed functional capablities assessment...This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that functional capabilities assessment forms for resident2 (R2) and R4 were not updated to reflect current needs of residents in care , which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2023
Plan of Correction
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Licensee will ensure functional capabilities form is updated for R2 and R4. Licensee to submit copies of completed form to LPA by POC due date.
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:Jennifer Fain
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/12/2023 03:36 PM - It Cannot Be Edited


Created By: Jennifer Fain On 05/12/2023 at 02:50 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: SOLIDUM CARE HOME #8
FACILITY NUMBER: 397000618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(c)(3)
Acceptance and Retention Limitations. (c) When a licensee admits or retains any person 60 years of age or older, the licensee shall ensure that all of the following information is contained in the person's file. (3) Documentation of a medical assessment...made within the last year. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did not comply with the section cited above. Licensee did not ensure an updated medical assessment for resident2 (R2) and R4 per regulatory requirements, which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 05/22/2023
Plan of Correction
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Licensee will update medical assessments (LIC 602) forms for R2 and R4 and send copies of completed updated forms to LPA by POC due date.

Licensee will read regulation 85068.4(c) and submit a signed declaration of understanding to LPA by POC due date.
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:Jennifer Fain
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023


LIC809 (FAS) - (06/04)
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