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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002573
Report Date: 11/01/2023
Date Signed: 11/01/2023 11:39:03 AM

Document Has Been Signed on 11/01/2023 11:39 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:R & M RESIDENTIAL SERVICESFACILITY NUMBER:
455002573
ADMINISTRATOR:EINHORN, DANELLFACILITY TYPE:
735
ADDRESS:2565 SACRAMENTO DRIVETELEPHONE:
(530) 605-0535
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY: 4CENSUS: 4DATE:
11/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Danell Einhorn TIME COMPLETED:
11:45 AM
NARRATIVE
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On 11/1/2023, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Danell Einhorn 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, shed, and common restrooms.

LPA observed the facility to be clean and odor-free.

LPA observed each bathroom to have the necessary trash can with lid. LPA observed the second bathroom sink to be in disrepair. Hot water temperature was measured above the required temperature of 120 F.

Facility has a 2-day perishable and a 7-day non-perishable amount of food.

LPA observed one (1) fire extinguisher, six fire detectors, and one carbon monoxide detector.

In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of three (3) residents' files and four (4) staff files. LPA observed that Emergency Disaster Plan to be incomplete and outdated, the first three pages missing with the previous Administrator information.

Several topics were discussed.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.


An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A
copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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 11/01/2023 11:39 AM - It Cannot Be Edited


Created By: Jaynae Boyles On 11/01/2023 at 11:10 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: R & M RESIDENTIAL SERVICES
FACILITY NUMBER: 455002573

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023

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 observation, the licensee did not comply with the section cited above in one out of two bathrooms faucet was loose
which poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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The administrator agrees that the sink will be repaired within 30 days and will contact the LPA if more time is needed.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a 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).

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 in two of two sinks tested for water tempeture measured above the tempeture required by the regulation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
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Administrator agrees to turn the water heater down and monitor the water tempture by measuring weekly to ensure that he water tempeture remains within the regulation. Adminstrator will email the LPA a weekly log of the tempeture in one week.
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: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/01/2023 11:39 AM - It Cannot Be Edited


Created By: Jaynae Boyles On 11/01/2023 at 11:10 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: R & M RESIDENTIAL SERVICES
FACILITY NUMBER: 455002573

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that the emergency disaster plan was not completed as it was missing the first three pages, and it was not updated because it did not have the current administrator on the form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2023
Plan of Correction
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Administrator will update the form, and post at the facility. Administrator wil email the complated form to the LPA
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 Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


LIC809 (FAS) - (06/04)
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