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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002333
Report Date: 07/27/2023
Date Signed: 07/27/2023 11:54:39 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/27/2023 11:54 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PLATINUM HOMEFACILITY NUMBER:
455002333
ADMINISTRATOR:ZUMKEHR, ERICFACILITY TYPE:
735
ADDRESS:7279 PLATINUM WAYTELEPHONE:
(530) 247-0852
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY: 3CENSUS: 3DATE:
07/27/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator Cameron OlsonTIME COMPLETED:
12:15 PM
NARRATIVE
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On 07/27/2023, Licensing Program Analyst (LPA) Jaynae Boyles and Kerry Hiratsuka arrived at the facility unannounced to conduct a continuation 1-Year Required Annual Inspection. This is a follow-up visit to the inspection dated 07/17/2023. LPA's met with Facility Administrator Cameron Olson and explained the purpose of the visit.

LPA's Boyles, Hiratsuka 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, garage, backyard, and common restrooms.

LPA Boyles measured the water at 135 F, and the administrated measured the water at 119 F. It was discovered that the administrator had a incorrectly calibrated thermometer.

LPA Boyles observed the bathroom to be in need of repair. The administrator stated that there has been several work orders submitted to the property manager with no response. Some documentation was provided today regarding the follow-up for the repair, but it was not consistent. Administrator stated the shower has been patched a couple of times but now they are going to get it replaced August 22-25, 2023.

LPA reviewed a total of two (2) residents' files and two (2) staff files.

Several topics were discussed.

Deficiencies are being cited as a result of today’s inspection.

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

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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 07/27/2023 11:54 AM - It Cannot Be Edited


Created By: Jaynae Boyles On 07/27/2023 at 11:05 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PLATINUM HOME
FACILITY NUMBER: 455002333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2023
Section Cited
CCR
80088(e)(1)

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Furniture, Fixtures, Equipment, and Supplies. Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to
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Licensee shall sumbit a written plan to enusre that the tempeture is maintained between 105-120 F by 8/28/2023.
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attaina hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
Licensee failed this based on an incorrectly calibrated thermometer with the water measuring at 135 F which poses a potential risk to the clients in care
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Type B
08/28/2023
Section Cited
CCR80087(a)

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80087 Buildings and Grounds
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.
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Licensee shall submit a written plan for correcting the repairs to the bathroom if not completed as scheduled for 8/23-8/25.
The licensee shall submitt a written plan when addresing and managing the work orders for the facility.
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Licemsee failed based on not reparing the bathroom for an extended time.
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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 Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023


LIC809 (FAS) - (06/04)
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