471304415-11-27-2024-59-AS-SBEN-DBF2M5-20241127163033

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 471304415
Report Date: 11/27/2024
Date Signed: 11/27/2024 04:30:42 PM

Document Has Been Signed on 11/27/2024 04:30 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:	YREKA GUEST HOME		FACILITY NUMBER:	471304415
ADMINISTRATOR/ DIRECTOR:	CRANE, SANDEE JOY		FACILITY TYPE:	740
ADDRESS:	520 N. MAIN		TELEPHONE:	(530) 842-4235
CITY:	YREKA	STATE: CA	ZIP CODE:	96097
CAPACITY: 12	TOTAL ENROLLED CHILDREN: 0	CENSUS: 7	DATE:	11/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:45 PM
MET WITH:	Sandee Crane Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

NARRATIVE

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On 11/27/2024 at 01:45 PM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Sandee Crane Administrator (cert #7002868740 exp.02-18-26) and explained the purpose of the visit. Administrator certificate is current.

LPA Benson and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to seven (7) resident rooms, common areas, two (2) bathrooms, kitchen, storage areas and yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet.

The common area was clean, odor-free and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food.

The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguishers fully charged. Smoke detectors are all operational. Hot water temperature measured at 126.4, Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. All required postings are displayed within the facility.

No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was not recorded. The facility has not been conducting drills every 3 months.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, a copy of the report, and appeal rights provided to administrator.

Lauren Crocker	TELEPHONE: (916) 261-4966
Sarah Benson	TELEPHONE: 530-895-5033
	DATE: 11/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024

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 11/27/2024 04:30 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: YREKA GUEST HOME	FACILITY NUMBER: 471304415
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and interview, the licensee did not comply with the section cited above in one out of two faucets water temp. tested at 126.4 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/06/2024
	Plan of Correction
1 2 3 4	Administrator will adjust the water temp. Administrator will email LPA when complete.

Section Cited

Other Provisions

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly 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
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in the facility has not emergency and disaster paln which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2024
	Plan of Correction
1 2 3 4	The Administrator will create an emergency and disaster plan. The Administrator will send a copy of emergency and disaster plan to LPA. The Administrator will post a copy in the facility.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lauren Crocker	TELEPHONE: (916) 261-4966
Sarah Benson	TELEPHONE: 530-895-5033
	DATE: 11/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/27/2024 04:30 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: YREKA GUEST HOME	FACILITY NUMBER: 471304415
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in no record of fire/emergency drill done or recorded which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2024
	Plan of Correction
1 2 3 4	Administrator will plan and record a emergency drill. Administrator will email LPA when complete. Administraotr will plan and record an emergency drill quartley.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lauren Crocker	TELEPHONE: (916) 261-4966
Sarah Benson	TELEPHONE: 530-895-5033
	DATE: 11/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2024

LIC809 (FAS) - (06/04)

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