045002891-7-24-2023-59-AS-JBOS-CU2UFK-20230724153252

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045002891
Report Date: 07/24/2023
Date Signed: 07/24/2023 03:33:07 PM

Document Has Been Signed on 07/24/2023 03:33 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:	FOOTHILL COTTAGE		FACILITY NUMBER:	045002891
ADMINISTRATOR:	ABEJO, KRISTINE		FACILITY TYPE:	740
ADDRESS:	3064 CEANOTHUS AVENUE		TELEPHONE:	(530) 809-0418
CITY:	CHICO	STATE: CA	ZIP CODE:	95973
CAPACITY:	6	CENSUS: 3	DATE:	07/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:09 PM
MET WITH:	House Manager- Edmond Murillo		TIME COMPLETED:	03:45 PM

NARRATIVE

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On 07/24/2023, Licensing Program Analyst (LPA) Jaynae Boyles and Kerry Hiratsuka, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA's met with Facility House Manager Edmond Murillo and explained the purpose of the visit.

LPA Boyles, Hiratsuka and House Manager toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, shed, and common restrooms. LPA's 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, paper towels, trash can with lids and 20-second hand-washing poster. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 106 F. LPA's observed one fire extinguisher, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of three (3) residents' files and one (1) staff files.

Several topics were discussed.

The following deficiency was observed today:

-No Emergency disaster drill log. Per the regulations a emergency disaster drill shall be conducted quarterly for each shift.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left with the house manager.

Exit interview conducted and copy of report left at the facility.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 917-3040
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

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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Document Has Been Signed on 07/24/2023 03:33 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: FOOTHILL COTTAGE	FACILITY NUMBER: 045002891
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

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
1 2 3 4	Based on interview and review of files, the licensee did not comply with the section cited above an emergency disaster drill log was not produced which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2023
	Plan of Correction
1 2 3 4	By 8/18/2023 licensee shall conduct emergency disaster drills and keep a log of emergency disaster drills. Licensee shall create a plan to ensure that emergency disaster drills are completed and documented quarterly as required per regulations.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 917-3040
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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