502700342-11-27-2020-27-AS-VBRN-BVRU25-20201127141123

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700342
Report Date: 11/27/2020
Date Signed: 11/27/2020 02:12:21 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:	PATTERSON CAREHOME LLC		FACILITY NUMBER:	502700342
ADMINISTRATOR:	PAMITTAN, JEANNA		FACILITY TYPE:	740
ADDRESS:	142 PALOMINO WAY		TELEPHONE:	(650) 477-8065
CITY:	PATTERSON	STATE: CA	ZIP CODE:	95363
CAPACITY:	6	CENSUS: 4	DATE:	11/27/2020
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Jeanna Pamittan		TIME COMPLETED:	12:00 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	An Office Meeting was conducted today in the Sacramento Regional Office. The announced tele-visit was conducted via Conference call on 11/27/2020 at 11:00am due to COVID-19 and pre-cautionary measures. The purpose of this office meeting is to discuss the facilities staffing plan and resident location. Present in the meeting is Regional Manager Krystall Moore, Licensing Program Manager Stephen Richardson, Licensing Program Analyst Victoria Brown, Administrator Jeanna Pamittan. There is a census of 4 residents. There are 2 receiving hospital care, 1 at home with family and 1 at the facility at this time. During this call, the 1 resident in the facility became ill with possible covid symptoms and was sent to the hospital for evaluation. Administrator mentioned she wasn't feeling well last night and today. Administrator was informed to seek medical attention if and when necessary. At this time, 12:00pm there are no residents in the home. Issues discussed during the meeting were: -Staffing issues or lack there of...resources were given to Administrator on 11/25/20 and 11/27/20 via email. https://emsa.ca.gov/wp-content/uploads/sites/71/2020/05/MHOAC-Contact-List-05142020-Public.pdf direct link -Surveillance testing -Resident locations -Oversight plan -Temporary Manager option -Eviction

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2020

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 3

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: PATTERSON CAREHOME LLC	FACILITY NUMBER: 502700342
	VISIT DATE: 11/27/2020

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

The facility has stated they will do the following to achieve continued and substantial compliance:
-Submit contact information on relocation of the residents
-Seek alternative staffing option that may include putting temporary manager in place
-Continue following the suggestions from Public Health to include testing, isolation and quarantine.

LPA received contact information for residents responsible parties to be interviewed regarding relocations. Administrator stated that she is not closing the facility and is not evicting the residents. She intends to allow all the residents back into the facility.

During a review of the Community Care Licensing (CCL) daily covid call logs, it was revealed that the Administrator did not report a covid positive status to CCL in which the result was received by the facility on 11/24/20. The preponderance of evidence standard has been met. Therefore the facility will be cited during this visit for reporting requirements.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted with Jeanna Pamittan via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2020

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: PATTERSON CAREHOME LLC	FACILITY NUMBER: 502700342
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/27/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 11/28/2020 Section Cited	1 2 3 4 5 6 7	Reporting Requirements Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
	8 9 10 11 12 13 14	This regulation is not met as evidenced by: Based on a research of Licensing documents and interview with Administrator, a Covid positve was not reported to CCL This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2020

LIC809 (FAS) - (06/04)

Page: 3 of 3