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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002730
Report Date: 08/28/2024
Date Signed: 08/28/2024 11:05:15 AM

Document Has Been Signed on 08/28/2024 11:05 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:IPS- PICKFORD WAYFACILITY NUMBER:
455002730
ADMINISTRATOR/
DIRECTOR:		GARDNER, BONNIEFACILITY TYPE:
735
ADDRESS:20374 PICKFORD WAYTELEPHONE:
(530) 605-3605
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY: 4CENSUS: 3DATE:
08/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Administrator, Bonnie GardnerTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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On August 28, 2024 at approximately 10:15 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at IPS-Pickford Way for the purpose of conducting a Case Management-Deficiencies inspection. LPA was waiting for 20 minutes outside until the Administrator arrived. LPA was greeted outside the door by Administrator, Bonnie Gardner, and was granted access into the facility.

On August 2, 2024, the facility reported to Community Care Licensing that there was a medication error. Administrator disclosed that there was a Medication Error as it relates to ordering of the medication. Staff auditing medication did not advise that medication for a client was running low. Medication was ordered in the morning. LPA reviewed the Medication Order and confirmed that the medication is to be administered before bedtime (See LIC 809D). Administrator retrained staff on medication audits and implemented new medication checks for the facility.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 1 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this signed report along with appeal rights were given to the Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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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Document Has Been Signed on 08/28/2024 11:05 AM - It Cannot Be Edited


Created By: Farhaan Sarangi On 08/28/2024 at 10:53 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: IPS- PICKFORD WAY
FACILITY NUMBER: 455002730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2024
Section Cited
CCR
80075(b)

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80075(b):
Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by
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Licensee/Administrator shall conduct staff training with ALL staff who dispense medication. In addition, Licensee shall furnish to CCL a LIC 9098-self certification understanding of the regulation, a statement on how future compliance will be met.
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Based on a review of an incident report dated for August 5, 2024, that was forwarded to Community Care Licensing Regional Office (RO), the incident report reflects that a client missed a dosage of medication on August 2, 2024 due to the staff auditing medication did not advise that a medication was running low for a client in care. A review of the Physician Orders indicates that the medication is to be administered at night before bedtime which presents an immeidate health, safety and personal rights risk to the clients in care.
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Plan of Correction due: September 3, 2024

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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:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024


LIC809 (FAS) - (06/04)
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