397002923-4-28-2024-27-AS-CYAG-D4S9BD-20240428231323

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397002923
Report Date: 04/23/2024
Date Signed: 04/28/2024 11:13:44 PM

Document Has Been Signed on 04/28/2024 11:13 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:	REMOLONA FAMILY GUEST HOME		FACILITY NUMBER:	397002923
ADMINISTRATOR:	NORA REMOLONA		FACILITY TYPE:	740
ADDRESS:	360 BUTTON AVENUE		TELEPHONE:	(209) 823-9122
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	15	CENSUS: 15	DATE:	04/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Nena De La Cruz, Jon and Nora Remolona		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced annual visit made out to this facility on 04/23/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility staff person, Nena De La Cruz, who was requested by this LPA for her to go ahead and contact the facility designated Administrator, Nora Remolona, to inform her that CCL was present at this time. The facility designated Administrator arrived shortly thereafter to this facility while this LPA was conducting this annual visit. A brief interview was conducted with the facility designated Administrator at this time. It was learned that there were (5) residents under the care of hospice at this time. This facility has an approved hospice waiver for (6) residents at any given time. It was learned that there were (3) other residents who were receiving services through home health as well. This facility also has, on file, a program to accept and retain residents diagnosed with dementia at this time. Current census was 15 residents. A tour of this facility was conducted. Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Nora Remolona. Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet, located in kitchen hallway closet, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the facility designated Administrator at this time. The medication cabinet was observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: REMOLONA FAMILY GUEST HOME	FACILITY NUMBER: 397002923
	VISIT DATE: 04/23/2024

NARRATIVE

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Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Linen closet, located in the facility hallway cabinet, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 11/28/2023 by the local fire extinguisher company, Armor Fire Extinguisher Services, and in compliance at this time.
First aid kit was observed to be present and contained all of the required components at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted.

A review of (5) facility resident files was conducted and noted on the following LIC 858.
A review of (5) facility personnel files was conducted and noted on the following LIC 859.

The following forms and documents were requested to be updated and submitted into CCL:

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 Codes.

Appeal Rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/28/2024 11:13 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: REMOLONA FAMILY GUEST HOME	FACILITY NUMBER: 397002923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

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
1 2 3 4	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 134.2 degrees which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/24/2024
	Plan of Correction
1 2 3 4	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

87456(a)(3)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [1] out of [5] facility resident files did not have an updated annual medical assessment completed for a dementia diagnosis resident which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/24/2024
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all resident files diagnosed with dementia will be reviewed and updated as necessary. A statement of correction, along with copies of the updated LIC 602s for the dementia diagnosed residents, 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 King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 04/28/2024 11:13 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: REMOLONA FAMILY GUEST HOME	FACILITY NUMBER: 397002923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that several window screens had holes, rips, or tears in them which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/30/2024
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that a review of all window screens will be conducted. Any window screens with holes, rips, or tears in them will be repaired/replaced as needed. A statement of correction, along with a copy of all receipts for services rendered, will be completed and submitted into CCL by the due date.

Type B

Section Cited

CCR

87506(a)

Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	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: 04/30/2024
	Plan of Correction
1 2 3 4	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 King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

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