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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002618
Report Date: 01/03/2024
Date Signed: 01/03/2024 11:04:49 AM

Document Has Been Signed on 01/03/2024 11:04 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:DE MOLL HOMEFACILITY NUMBER:
455002618
ADMINISTRATOR:VICTORINE, CHAYLENEFACILITY TYPE:
735
ADDRESS:1213 DE MOLL DRIVETELEPHONE:
(530) 410-9627
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 3DATE:
01/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Chay VictorineTIME COMPLETED:
11:30 AM
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On 01/03/2024 Licensing Program Analyst (LPA) Ivan Avila arrived at the facility unannounced to conduct a 1-year annual inspection and found it to be vacant. LPA toured the exterior premises and then observed a client inside, LPA asked client to open the door. Client let LPA inside the facility and no other staff were present and client was left unattended at the facility. Administrator Chay Victorine arrived later at the facility and LPA explained the purpose of the visit. LPA and Administrator toured the facility to ensure the health and safety of clients in care.
Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects are stored in locked cabinet inaccessible to residents. Hot water temperature measured at 108 degrees. Bedrooms: The LPA observed client bedrooms furnished with at least one night stand, bed, and sufficient lighting for each client. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Bathrooms: The LPA observed the client's bathroom to be clean, and properly supplied. Clients have sufficient supplies for personal hygiene. Common Areas: These included the living, and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture and there are no bodies of water or fire arms on the premises. The LPA observed the washer and dryer and cleaning supplies are locked in a cabinet inaccessible to residents. Record Review: A review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill. The LPA reviewed three (3) staff, and three (3) client files. All documents reviewed appeared complete and current.

Continued on LIC809C

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DE MOLL HOME
FACILITY NUMBER: 455002618
VISIT DATE: 01/03/2024
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Medications: During the facility visit a medications review was initiated. Medications are centrally stored and locked in a cabinet inaccessible to clients in care; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during today’s visit are documented on the LIC809-D page.

An exit interview was held, and a copy of the report and appeal rights were provided to Administrator Chay Victorine.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/03/2024 11:04 AM - It Cannot Be Edited


Created By: Ivan Avila On 01/03/2024 at 10:47 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: DE MOLL HOME
FACILITY NUMBER: 455002618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
85065(b)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 client was at the facility alone and no staff were present, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/08/2024
Plan of Correction
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Licensee agree to conduct staff training on following consistent protocols with staff being present when a client is at 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:Anthony Perez
LICENSING EVALUATOR NAME:Ivan Avila
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024


LIC809 (FAS) - (06/04)
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