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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500332206
Report Date: 03/06/2024
Date Signed: 03/12/2024 10:25:06 AM

Document Has Been Signed on 03/12/2024 10:25 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DEL RIO GUEST HOMEFACILITY NUMBER:
500332206
ADMINISTRATOR:ASHLYNN BURCHFACILITY TYPE:
735
ADDRESS:2841 PATTERSON RDTELEPHONE:
(209) 869-2420
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY: 15CENSUS: 9DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ashlynn BurchTIME COMPLETED:
02:00 PM
NARRATIVE
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Unannounced Annual visit made out to this facility on 03/06/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Ashlynn Burch. A brief interview was conducted with the facility designated Administrator at this time.
It was learned that this facility was vendorized through Valley Mountain Regional Center to be able to accept and retain Level 2 residents at any given time.
This facility was to maintain a 2:11 ration for staff to residents at all times.
Current census was 9 residents.
It was learned that there weren't any residents under the care of hospice at this time.
It was learned that there weren't any residents diagnosed with dementia at this time.
A tour of this facility was conducted.
Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Ashlynn Burch. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the Administrator Cert #6065824735 to expire on 01/29/2025.
Kitchen area was toured. Cabinets and drawers were reviewed.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinets and supplies, located in a laundry room, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator at this time. This medication cabinet was observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Linen closets, located in the facility hallway, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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: DEL RIO GUEST HOME
FACILITY NUMBER: 500332206
VISIT DATE: 03/06/2024
NARRATIVE
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Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 01/10/2024 by the local fire extinguisher company, Jorgensen Co. and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.
A review of (5) facility resident records was conducted and noted on the following LIC 858 form.
A review of (5) facility staff records was conducted and noted on the following LIC 859 form.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/12/2024 10:25 AM - It Cannot Be Edited


Created By: Charlie Yang On 03/06/2024 at 01:53 PM
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: DEL RIO GUEST HOME
FACILITY NUMBER: 500332206

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 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 since the hot water being dispensed was measured at 133.0 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2024
Plan of Correction
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Facility designated Administrator stated that the hot water heater will be immediately dialed down and the hot water being dispensed will be measured for the next (7) days. A statement of correction, along with (7) days worth of hot water temperatures, will be completed and submitted into CCL by the due date.
Type A
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [5] facility personnel files did not have a verified TB clearance from a licensed medical professional which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2024
Plan of Correction
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Facility designated Administrator stated that the facility staff member will be immediately scheduled, with their licensed medical professional, to obtain an updated/verified TB clearance. A statement of correction, along with a copy of the verified TB clearance, will be completed and submitted into CCL by the due date.
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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/12/2024 10:25 AM - It Cannot Be Edited


Created By: Charlie Yang On 03/06/2024 at 01:53 PM
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: DEL RIO GUEST HOME
FACILITY NUMBER: 500332206

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [5] facility personnel files did not have certified/updated First Aid Training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2024
Plan of Correction
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Facility designated Administrator stated that the facility staff member will be immediately scheduled to undergo and complete First Aid Training and obtain an updated certificate. A statement of correction, along with a copy of updated First Aid Training, will be completed and submitted into CCL by the due date.
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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/12/2024 10:25 AM - It Cannot Be Edited


Created By: Charlie Yang On 03/06/2024 at 01:53 PM
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: DEL RIO GUEST HOME
FACILITY NUMBER: 500332206

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 several windows were missing window screens and certain screens contained holes, rips, or tears in them which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Facility designated Administrator stated that all facility windows and window screens will be reviewed. Any windows missing screens will be replaced with them and any found to contain holes, rips, or tears in them will be repaired and replaced. A statement of correction, along with a copy of the receipt for services provided for the window screens, will be completed and submitted into CCL by the due date.
Type B
Section Cited
CCR
80070(b)
Client Records
(b) Each record must contain information including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [3] out of [5] facility resident files were missing required forms and documents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Facility designated Administrator stated that all facility resident files will be reviewed. Any, and all, missing forms and documents will be updated to make sure that the files are complete. A statement of correction, along with a copy of the missing forms and documents, will be completed and submitted into CCL by the due date.
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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
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