502700233-8-26-2021-27-AS-AJON-C69UTK-20210826155205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700233
Report Date: 08/26/2021
Date Signed: 08/26/2021 03:52:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	DAVIS GUEST HOME #8		FACILITY NUMBER:	502700233
ADMINISTRATOR:	SPEEGLE, MISTY		FACILITY TYPE:	740
ADDRESS:	5348 KIERNAN AVENUE		TELEPHONE:	(209) 622-2042
CITY:	SALIDA	STATE: CA	ZIP CODE:	95368
CAPACITY:	80	CENSUS: 73	DATE:	08/26/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:07 PM
MET WITH:	Misty		TIME COMPLETED:	02:15 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Albert Johnson conducted a case management incident check on this day. LPA met with Administrator.

During the course of the investigation: Case Report Investigations # FD2721-04046 regarding the death of R1, it was confirmed that the facility has no records of bed checks, "Q30" (every 30 minutes) checks or sign in and out sheets for the day of the incident. Administrator Misty Speegle was requested to give bed checks and Q30 checks. These are kept for approximately 48 hours, Sign in and out sheets are kept for approximately one month. The information was shared with the department through documented charting in the residents' file.

The facility does not keep Medication Administration Record (MAR) sheets. Per Administrator Misty, the medication is dispensed from "bubble packs." The bubble packs are initialed and discarded at the end of the month. R1's medication bubble packs were discarded and medications were destroyed per regulation requirements and documented on the central stored log.

Administrator Misty could not provide me a written protocol for residents going AWOL. She advised me staff call the administrators and they instruct staff what to do. This information is shared with staff in the facilities' "team book."

At 1:05am on the day of the incident, Administrator Heather instructed staff to report R1 as AWOL. However, per Stanislaus Sheriff’s Department' the call came in at 0214 hours. Continued

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DAVIS GUEST HOME #8	FACILITY NUMBER: 502700233
	VISIT DATE: 08/26/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Administrator nor staff could not explain why R1 was reported missing an hour after the administrator instructed them to do so. Based on the protocol from the facility and the sheriff's department the information that is required to be in place at the time of an event (i.e. AWOL, etc.) was being completed and prepared. This information includes a picture and other information that is put onto a missing person report and provided to the deputy when he arrives at the facility.

Based on the interview and records reviewed with Misty regarding these concerns there will be no deficiencies cited.

Exit interview conducted.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2