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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000618
Report Date: 01/05/2024
Date Signed: 01/05/2024 12:37:26 PM

Document Has Been Signed on 01/05/2024 12:37 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 3DATE:
01/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Lynn CaoliTIME COMPLETED:
12:45 PM
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On 1-5-24 at 11:37am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding Administrator Qualifications and Duties. LPA met with Administrator Lynn Caoli and explained the purpose of the visit. LPA reviewed documents related to complaint investigation #27-AS-20230914092803. Based on documents reviewed, it was determined that on 9-7-23, resident1 (R1) was witnessed to have leg wound bandages described at "old, dingy, and covered in blood and puss." It was further revealed that R1's bandages were not changed in accordance with R1's care plan, nor bathed in accordance with care plan, which resulted in worsening of leg wounds including maggot infestation on 9-7-23. As a result, it is determined that Administrator did not exercise a provision of service to ensure R1's care plan was followed.

As a result of today's case management, citation are issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Lynn Caoli and a copy of this report was provided to Lynn. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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 01/05/2024 12:37 PM - It Cannot Be Edited


Created By: Michael Bilger On 01/05/2024 at 11:53 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SOLIDUM CARE HOME #8
FACILITY NUMBER: 397000618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/08/2024
Section Cited
CCR
85064(j)(4)

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Administrator Qualifications and Duties. (j) The administrator shall perform the following duties: (4) Provision of, or insurance of the provision of, services to the clients... including those services identified in the client's individual needs and services plans. This requirement was not me as evidenced by:
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Licensee and designees to read regulation 85064(j)(4) and submit a signed declaration of understanding to LPA by POC due date.

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Based on record review, Administrator did not ensure the provision of service to resident in care which resulted in worsening of wounds and maggot infestation. This posed an immediate health and safety risk to residents in care.
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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:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024


LIC809 (FAS) - (06/04)
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