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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397203027
Report Date: 04/04/2023
Date Signed: 04/24/2023 04:29:43 PM

Document Has Been Signed on 04/24/2023 04:29 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:WYCOFF FAMILY CARE HOMEFACILITY NUMBER:
397203027
ADMINISTRATOR:WYCOFF, STACYFACILITY TYPE:
735
ADDRESS:3908 SETROK COURTTELEPHONE:
(209) 996-4487
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 6DATE:
04/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mandy WittharTIME COMPLETED:
03:45 PM
NARRATIVE
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Unannounced annual inspection conducted by Licensing Program Analysts (LPAs) Kimberly Viarella and Charlie Yang. LPAs identified themselves and the purpose of their visit to staff and instructed them to contact the designated facility administrator to let them know of their arrival. A brief interview of staff revealed that the current census was 6 residents of which 2 residents were present while 4 residents were out at this time. LPAs were also told that there were 2 staff members working today. LPAs were led into the house and set up in the dining room while they were waiting for the administrator to arrive.

Mandy Witthar, administrator assistant, arrived and provided a tour of the facility. LPAs were shown the common rooms and there was enough furniture, furnishings and lighting to be in compliance at the time. The laundry room was then inspected and the LPAs observed cabinets with locks above the washer and dryer. A bathroom was adjacent to this space and LPAs measured the hot water to ensure that it was within 105 and 120 degrees as required. LPAs also inspected underneath the bathroom cabinets to ensure that no toxic chemicals were present.

The tour progressed to the garage. There LPAs observed locked cabinets where chemicals and other locked cabinets with non-perishable items. Staff and employee files were also located in a cabinet in the garage. LPAs exited the garage and performed an exterior inspection of the facility.

LPAs observed a 6 foot deep in-ground pool in the backyard. The yard was enclosed by a fence. There was a patio and sitting area for residents along with a portable basketball hoop. LPAs were led to a shed on the side of the house. LPAs asked the assistant administrator to unlock the shed and LPAs observed miscellaneous storage. LPAs proceeded back into the house and the tour continued in the kitchen. LPAs instructed the administrator assistant to open all cabinets and drawers to ensure that all sharps and medications were secured and not accessible to ensure the safety of residents in care. LPAs also inspected the refrigerator and storage areas to ensure that there was a sufficient food supply of 7 days of
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2023
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: WYCOFF FAMILY CARE HOME
FACILITY NUMBER: 397203027
VISIT DATE: 04/04/2023
NARRATIVE
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non-perishable food items and 2 days of perishable food items.

Stacy Wycoff, the licensee, arrived and joined the tour as the group progressed to the upper level of the facility. LPAs inspected resident bedrooms. The three bedrooms were double occupancy and each contained the required furniture and lighting to be in compliance. LPAs also viewed one staff room located on the same floor. The linen supply was also inspected and found to be sufficient for the persons in care. There were two bathrooms on this floor and both were found to be in compliance.

There were two fire extinguishers, one located in the hallway of the first floor, and the second in the hallway above. Both were inspected on 10/20/2022 by Stanislaus Fire.

Medications were centrally stored and in a cabinet with a combination lock in the kitchen. Policies and procedures regarding storage and dispensing were discussed. The First Aid kit was inspected and found to be complete with all of the required items.

LPAs reviewed 4 staff files and 3 resident files. For the resident files, LPAs looked for the following: a signed and dated admissions agreement, a physician’s report, proof of a negative TB test, ambulatory/non-ambulatory status, ID and emergency information, an appraisal and needs service plan, a centrally stored medication destruction record, safeguards for cash resources, safeguards for property/valuables, statement of personal rights, and cash resources information. For the staff files, LPAs looked for the following: first aid certificate, fingerprint clearances/exemptions, personnel record/job application, health screening, proof of negative TB test, medical training verification, employee rights, and criminal record statement.

According to the California Code of Regulations (Title 22, Division 6, the LPA observed the following deficiencies listed on the LIC 809 D.

An exit interview was conducted with the Licensee.. Copies of the Facility Evaluation Report and Appeal Rights were provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

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

DATE: 04/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/24/2023 04:29 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 04/04/2023 at 02:22 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: WYCOFF FAMILY CARE HOME
FACILITY NUMBER: 397203027

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 when the LPA opened the unlocked medication cabinet in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2023
Plan of Correction
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The Licensee will post a sign reminding staff to check the lock on the medication cabinet This sign, along with a medication storage training plan, will be submitted to CCL at kimberly.viarella@dss.ca.gov.
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:Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/24/2023 04:29 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 04/04/2023 at 02:22 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: WYCOFF FAMILY CARE HOME
FACILITY NUMBER: 397203027

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 when the LPAs witnessed missing screens on the second floor of trhe faciltiy and broken lock on the shed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2023
Plan of Correction
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The Licensee will submit pictures to CCL at kimberly.viarella@dss.ca.gov by 04/14/2023.
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:Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023


LIC809 (FAS) - (06/04)
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