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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045000700
Report Date: 11/28/2023
Date Signed: 11/28/2023 02:57:30 PM


Document Has Been Signed on 11/28/2023 02:57 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:COURTYARD AT LITTLE CHICO CREEK, THEFACILITY NUMBER:
045000700
ADMINISTRATOR:MORALES, MELISSAFACILITY TYPE:
740
ADDRESS:1770 HUMBOLDT ROADTELEPHONE:
(530) 342-0707
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:49CENSUS: 40DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Administrator Melissa Morales TIME COMPLETED:
03:15 PM
NARRATIVE
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On 11/28/2023, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Melissa Morales and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, backyard, and common restrooms.

LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair. Hot water temperature was measured within the required range.

Facility has a 2-day perishable and a 7-day non-perishable amount of food. Facility offered a variety of menu options for the residents, and has a two part process to verify residents have attended meal time or received meal service in their room.

LPA observed an activity calendar with a variety of activities available to the residents. LPA observed an activity room which had supplies for painting, puzzles and games.

LPA observed several fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed. First aid is complete and ready for use.

Administrator was unable to provide documentation of quarterly emergency disaster drills.

LPA reviewed a total of five (5) residents' files and five (5) staff files. One staff file missing a criminal clearance. One resident who is diagnosed with dementia is missing an updated medical assessment within the last 12 months.

Several topics were discussed.

California Code of Regulations, (Title 22), is being cited on the attached LIC809D. A civil penalty for $100 per day for a maximum of 5 days, totaling $500 for criminal record clearance violation is being assessed on the attached LIC 421BG. An exit interview was conducted, and Plans of Corrections were reviewed and developed with the Administrator.



A copy of this report, LIC 809-D, LIC421BG, and Appeal Rights were discussed and provided to Administrator.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 11/28/2023 02:57 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: COURTYARD AT LITTLE CHICO CREEK, THE
FACILITY NUMBER: 045000700

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)
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: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:

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 one out of five staff file reviews did not have a Criminal Records Clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2023
Plan of Correction
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The administrator will ensure that all staff have a Criminal Records Clearance when employed with the facility.
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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/28/2023 02:57 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: COURTYARD AT LITTLE CHICO CREEK, THE
FACILITY NUMBER: 045000700

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 zero out of four emergency disaster drills were conducted within a 12 month time period which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2023
Plan of Correction
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Administrator will create a plan to ensure that all emergency disaster drills are conducted quarterly, taking into account different emergency scenarios and documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.

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 one out of five resident files reviewed a resident with dementia did not have an annual medical assessment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Administrator will complete and update the medical assessment for this resident. Administrator will ensure that all residents with dementia will have an updated medical assessment annually.
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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3