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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500309303
Report Date: 01/10/2024
Date Signed: 01/10/2024 04:00:32 PM


Document Has Been Signed on 01/10/2024 04:00 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:J & L GUEST HOMEFACILITY NUMBER:
500309303
ADMINISTRATOR:ANITA NIELFACILITY TYPE:
740
ADDRESS:237 S ABBIE STREETTELEPHONE:
(209) 527-2765
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY:32CENSUS: 26DATE:
01/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Renee Little, AdministratorTIME COMPLETED:
04:30 PM
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On 1/10/23 at 1:15pm, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct two case management visits regarding a resident fall incident report on 01/04/2023 and a peer to peer altercation which occurred on 01/03/2024. LPA met with Renee Little, Administrator and explained the purpose of the visit. LPA reviewed an incident report dated 01/04/2023 and conducted a brief interview with Sarah Rico, House Manager. Based on an incident report, on 01/04/2023 resident 1 (R1) became agitated after their routine was disrupted by another peer (R2). An altercation resulted in which R1 pinched R2 on the stomach. R2 responded by punching R1 in the eye, resulting in a black eye. Based on an incident report and interview, R2 had no noticeable injuries but was taken to the hospital for X rays due to an older injury.

The incident was reported to the licensing department, the service coordinators for both R1 and R2, and R1’s father within regulatory time frames. A team meeting for staff was held on 01/04/2023. The House Manager discussed factors that may be contributing to R1’s aggression such as the loss of her mother in addition to the holidays. Staff were urged to identify moments in R1’s routine when she is most likely to be triggered. Staff would then redirect R1 by supporting them in being patient when other residents disrupt the schedule and/or help R1 to make better behavioral choices

The incident for R3 occurred on 01/04/2023. R3 uses a walker and usually showers while staff monitors them. The House Manager stated that R3 self reported that he had gotten into the shower on his own without staff monitoring him and had fallen and gotten himself up. R3 was unable to recount when the fall occurred other than “a few days ago”. None of the staff reported observing R3 fall during a shower. R3 reported he was sore and in pain on 01/04/23 and was asked if he wanted to go to the ER but declined. The next day, House Manager Sarah Rico inquired about his arm and R3 reported that it was “a little sore” per the House Manager. R3 is now scheduled to be seen by a Nurse Practitioner for a home visit on 01/15/2023 instead. This is the first incident of falling in the shower with R3. R3’s Service Coordinator Juanita Cardona was informed of the fall. Staff urged R3 to inform them if he wanted a shower in the future.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: J & L GUEST HOME
FACILITY NUMBER: 500309303
VISIT DATE: 01/10/2024
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 A review of R3’s 602 shows that he is non-ambulatory and uses a walker and that he must be monitored when showering. This is the first known incident when R3 tried to get in the shower on his own.

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 deficiencies may result in civil penalties.



Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 01/10/2024 04:00 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: J & L GUEST HOME
FACILITY NUMBER: 500309303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2023
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement was not met as evidenced by:
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Licensee agrees provide reassessment for R3 with updated 602 and will submit a plan outlinining procedures on maintaining awareness of residents whereabouts. Plan to be submitted to LPA by POC due date.
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Based on observation and record review, the facility did not provide supervision as necessary to meet the client’s needs. Which poses a potential Health, Safety or Personal Rights risk to residents in care.
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
LIC809 (FAS) - (06/04)
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