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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002764
Report Date: 05/07/2024
Date Signed: 05/07/2024 12:07:30 PM


Document Has Been Signed on 05/07/2024 12:07 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:SAINT LORENZ ASSISTED LIVINGFACILITY NUMBER:
455002764
ADMINISTRATOR:BIRD, JAMESFACILITY TYPE:
740
ADDRESS:740 LAKE BLVDTELEPHONE:
(650) 632-5300
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:17CENSUS: 15DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Administrator- Shirl Freeman TIME COMPLETED:
12:30 PM
NARRATIVE
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On 05/07/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. LPA observed the facility to be clean, in good repair and odor-free.

Areas toured include but are not limited to: common areas, resident bedrooms, backyard, shed, and common restrooms. LPA observed 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. LPA observed each bedroom to have the required furnishings, working lights and windows with screens. LPA observed the medications and toxic chemicals to be locked and inaccessible to residents.

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 above the required regulation temperature. LPA observed fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed the first aid kit to be complete and ready for emergency use. LPA observed a completed emergency disaster plan and the required emergency disaster drills. LPA observed residents to have half bed rails with no orders from a doctor for the utilization of the bed rails.

LPA reviewed a total of six (6) residents' files and four (4) staff files which contained all of the required documentation.

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.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 05/07/2024 12:07 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: SAINT LORENZ ASSISTED LIVING
FACILITY NUMBER: 455002764

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 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 that the water was measured above regulation in serveral locations throughout the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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The facility will monitor the water tempeture one time a week for six months. Facility will ensure that the water is measured between 105-120 degrees.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview, record review, the licensee did not comply with the section cited above in three out of six files reviewed in which the residents had bed rails did not have an order from a physician which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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The facility will ensure that al residents who have bed rails have an order from the physician. The facility will obtain an order from a physician for residents who have bed rails.
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 CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4