502700235-12-4-2023-27-AS-MJEN-CY83FQ-20231204171307

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700235
Report Date: 12/04/2023
Date Signed: 12/04/2023 05:14:11 PM

Document Has Been Signed on 12/04/2023 05:14 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:	EL RIO MEMORY CARE COMMUNITY		FACILITY NUMBER:	502700235
ADMINISTRATOR:	KENT E MULKEY		FACILITY TYPE:	740
ADDRESS:	2828 HEALTHCARE WAY		TELEPHONE:	(209) 543-3805
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	72	CENSUS: 58	DATE:	12/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kent Mulkey		TIME COMPLETED:	04:30 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	On 12/4/23 at approximately 10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met with Administrator Kent Mulkey and explained the purpose of today's visit. LPA Jensen toured the exterior of the facility and observed all pathways to be clear of obstruction. The grounds were maintained and contained adequate outdoor furniture and shaded areas for resident outdoor activities. LPA Jensen toured the interior of the facility and observed the facility to be sanitary and odor free. The furniture and equipment were observed to be in good repair. LPA Jensen toured 3 resident rooms. LPA Jensen observed a bottle of wine in 1 room and Lysol disinfectant spray, wound care solution and scissors in another room. The disinfectant spray, wound care solution and scissors appeared to be supplies that were being used by a home health nurse or hospice care worker. All resident rooms were adequately furnished and had adequate lighting. A signal system is available in all resident rooms and was verified to be in good working order. The water temperature in resident rooms was measured at 106 degrees Fahrenheit which is in compliance. The thermostat for the facility was set at 77 degrees which is in compliance. LPA Jensen toured the kitchen and observed lunch being prepared. The kitchen was observed to be sanitary. The refrigerator and freezer temperatures were in compliance. LPA Jensen observed a 2 day supply of perishable food however there was less than a 7 day supply of non-perishable food on site. The Ansul system was last serviced in November of 2023 and is in compliance. There are two dining rooms available for residents. A menu is posted for the month.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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: EL RIO MEMORY CARE COMMUNITY	FACILITY NUMBER: 502700235
	VISIT DATE: 12/04/2023

NARRATIVE

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LPA Jensen tested the carbon monoxide detectors and determined them to be in good working order. The smoke detectors are hard wired. LPA Jensen reviewed the disaster emergency plan and determined it to be in compliance.

LPA Jensen reviewed 10 staff files. 1 of 10 files had a first aid certification that expired December of 2022. 1 of 10 files did not have a first aid certification on file. LPA Jensen reviewed 4 resident files. 2 of 4 resident files did not have Physician's report that was completed within the last year.

LPA Jensen requested copies of the Infection Control Plan and LIC 500. Technical assistance was provided for the facility to designate an Infection Control Preventionist.

The Inspection tool was used during the course this inspection.

An exit interview was conducted and a copy of this report, an LIC 811 and appal rights were provided.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/04/2023 05:14 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: EL RIO MEMORY CARE COMMUNITY	FACILITY NUMBER: 502700235
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Jensen's observation of the facility food supply, the licensee did not comply with the section cited above in maintaining a 7 day supply of non-perishable food which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	The Licensee will scan and send the food order to LPA Jensen by the POC due date.

Type B

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Jensen's observation of 1 resident room with alcohol and 1 resident room with disinfectants, the licensee did not comply with the section cited which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/11/2023
	Plan of Correction
1 2 3 4	The Licensee agrees to conduct an inventory of all resident rooms and remove items in the above listed regulation. The facility agrees to email an attestation by the POC to LPA Jensen that all residnet rooms have been checked.

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 Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 12/04/2023 05:14 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: EL RIO MEMORY CARE COMMUNITY	FACILITY NUMBER: 502700235
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Jensen's record review of staff files, the licensee did not comply with the section cited above in 2 out of 10 counts which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/04/2024
	Plan of Correction
1 2 3 4	The Licensee agrees to have all staff that assist with resident activities of daily living obtain current first aid certifications and will email LPA Jensen proof of correction by POC due date.

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.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

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