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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002923
Report Date: 04/21/2023
Date Signed: 04/25/2023 09:14:39 AM


Document Has Been Signed on 04/25/2023 09:14 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:REMOLONA FAMILY GUEST HOMEFACILITY NUMBER:
397002923
ADMINISTRATOR:NORA REMOLONAFACILITY TYPE:
740
ADDRESS:360 BUTTON AVENUETELEPHONE:
(209) 823-9122
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:15CENSUS: 15DATE:
04/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nena De la Cruz and Nora RemolonaTIME COMPLETED:
02:30 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 04/21/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Nena De la Cruz, who was requested by this LPA to go ahead and contact the facility designated Administrator, Nora Remolona, to inform her that CCL was present at this time to conduct an annual visit. Contact was made with the facility designated Administrator, Nora Remolona, over the facility telephone and she stated that she was an hour and a half away from this facility. This LPA stated that he will conduct the visit and await her arrival.
The facility designated Administrator arrived later to this facility while this LPA was conducting this annual visit.
It was learned that there were (3) residents under the care of hospice at this time. This facility does have a hospice waiver to accept and retain up to (6) residents at any given time.
It was learned that there were (3) residents under the care of home health with (7) residents diagnosed with dementia at this time.
Current census was 15 residents.
Tour of this facility was conducted.
Dining area, living area, and all other areas intended for use by the facility residents were toured. Furniture and furnishings were reviewed to make sure that they were in good repair and able to meet the needs of the residents at this time.
Kitchen area was toured. Food storage unit, refrigerator/freezer, was observed to be present. A review of the facility's 2-day perishable and 7-day nonperishable food supply was conducted. Additional food storage units, located in the interior kitchen walkway, was observed to be in use and reviewed by this LPA at this time.
Medication cabinet, located in the facility kitchen cabinet, was reviewed. Policies and procedures related to storing, handling, and documentation of the facility resident medications were discussed with the facility caregiver at this time.
First aid kit, located in medication cabinet, was observed to contain all of the required components at this time.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
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: REMOLONA FAMILY GUEST HOME
FACILITY NUMBER: 397002923
VISIT DATE: 04/21/2023
NARRATIVE
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A tour of the facility resident bedrooms was conducted. A review was performed to make sure that the bedroom furniture and furnishings were in good repair and able to meet the needs of the residents at this time.
A tour of the facility resident restrooms was conducted. A review was performed to make sure that the restrooms were in good repair and able to meet the needs of the residents at this time.
Hot water temperatures were taken, in two of the resident restrooms, and measured to make sure that they were within the allowed range of 105-120 degrees at all times.
Grab bars and non skid mats/surfaces were observed to be present and in compliance at this time.
Linen closets (2) located in the facility hallway were reviewed.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 11/219/2022 by the local fire extinguisher company, Armor Fire Extinguisher Company, and in compliance at this time.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all exits was conducted.
A review of (5) facility resident files was conducted.
A review of (5) facility staff files was conducted.

The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

LIC 308

LIC 400

LIC 500

LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.
Appeal rights were printed and a copy was given to the facility designated Administrator at this time.
Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 04/25/2023 09:14 AM - It Cannot Be Edited

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: REMOLONA FAMILY GUEST HOME
FACILITY NUMBER: 397002923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in [2] out of [2] resident restroom faucets where the hot water temperature was measured at 141.2 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2023
Plan of Correction
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The facility designated Administrator stated that the hot water heater will be turned down to make sure that the hot water that is dispensed will always be within the allowed range of 105-120 degrees. A statement of correction, along with readings for the next 24 hours, will be recorded and submitted into CCL by the due date.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in [2] out of [2] resident restrooms had disinfectants present, and made available, to residents. In addition, the exterior laundry room was found to be unlocked which housed detergents, bleach, and additional cleaning supplies which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2023
Plan of Correction
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The facility designated Administrator stated that the disinfectants will be removed from all resident restrooms and properly stored and made inaccessible to the residents at all times. In addition, the laundry room will be locked and made inaccessible to residents at all times. A statement of correction will be submitted into CCL by the 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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 04/25/2023 09:14 AM - It Cannot Be Edited

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: REMOLONA FAMILY GUEST HOME
FACILITY NUMBER: 397002923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [5] out of [5] personnel records were missing required forms and documents related to TB clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2023
Plan of Correction
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The facility designated Administrator stated that the personnel records will be reviewed and all facility staff providing care and supervision to the residents will be TB cleared with documented proof on file at all times. A statement of correction, along with documented cleared TB and updated health screenings, will be completed and submitted into CCL by the due date.
Type A
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [5] personnel files were missing required initial/ongoing staff training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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The facility designated Administrator stated that the personnel records will be reviewed and all facility staff providing care and supervision to the residents will be properly trained with documented proof on file at all times. A statement of correction, along with documented training, will be completed and submitted into CCL by the 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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 04/25/2023 09:14 AM - It Cannot Be Edited

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: REMOLONA FAMILY GUEST HOME
FACILITY NUMBER: 397002923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Requirements - General
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type A
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [5] persons did not have documented required 10 hours of initial training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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The facility designated Administrator stated that the personnel records will be reviewed and all facility staff providing care and supervision to the residents will receive and complete the required 10 hours of initial training with documented proof on file at all times. A statement of correction, along with documented completion of 10 hours of initial training, will be completed and submitted into CCL by the 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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 04/25/2023 09:14 AM - It Cannot Be Edited

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: REMOLONA FAMILY GUEST HOME
FACILITY NUMBER: 397002923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(b)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [3] out of [5] personnel records were missing forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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The facility designated Administrator stated that the personnel records will be reviewed and all facility staff providing care and supervision to the residents will be updated to contain all required forms and documents at all times. A statement of correction, along with copies of the updated staff files, will be completed and submitted into CCL by the due date.
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [5] out of [5] resident files were missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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The facility designated Administrator stated that the resident records will be reviewed and updated to contain all required forms and documents at all times. A statement of correction, along with copies of all updated forms and documents, will be completed and submitted into CCL by the 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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6