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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700342
Report Date: 11/07/2022
Date Signed: 11/09/2022 10:33:41 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/09/2022 10:33 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:PATTERSON CAREHOME LLCFACILITY NUMBER:
502700342
ADMINISTRATOR:PAMITTAN, JEANNAFACILITY TYPE:
740
ADDRESS:142 PALOMINO WAYTELEPHONE:
(650) 477-8065
CITY:PATTERSONSTATE: CAZIP CODE:
95363
CAPACITY:6CENSUS: 4DATE:
11/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Esther M. and L. AcostaTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with two staff prior to Jeanna Pamittan joining the inspection approximately twenty minutes later.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 115.5 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 4 resident and 2 staff files, including criminal record clearances. During the resident file review LPA observed an outdated Physician's report for R1 and medication prescribed by a Veterinary (DVM) Doctor of Veterinary Medicine for an infection (R1 has not seen the MD Medical Doctor , NP Nurse Practitioner or a PA Physician's Assistant for an alleged Urinary tract infection), the medication was prescribed on 11/5/2022 by a DVM with the quantity of 42 the count today was 40. LPA also observed missing PRN letters for R1 and R2 (Advisory given). Fire drill was completed on 10/13/2022.

All staff are Fingerprint cleared and associated to the facility. First aid kit was checked and is complete

Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Advisories Given.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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


Document Has Been Signed on 11/09/2022 10:33 AM - 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
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: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2022
Section Cited

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(4) The licensee shall assist residents with self-administered medications as needed.
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following:
(A) Medications usually prescribed for self-administration which have been authorized by the person's physician.
(B) Medications during an illness determined by a physician to be temporary and minor.
(C) Assistance required because of tremor, failing eyesight and similar conditions.
(D) Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication.
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
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This requirement was not met as evidenced by records review and interview with the Administrator. Medication prescribed by a Veterinary (DVM Brooks) for an infection was in the medication box for R1 (R1 has not seen the Doctor for an alleged Urinary tract infection), the medication was prescribed on 11/5/2022 with the quantity of 42 the count today was 40. This poses an immediate safety concern for resident in care
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and why R1 was not taken to the ER or other medical facility to address the suspected UTI by the close of business today.

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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/09/2022 10:33 AM - 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
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: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/25/2022
Section Cited

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87705(c)(5) Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually.-
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This was not met as evidenced by Records review R1 has an outdated 602 on file date 7/2020.
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Type B
11/18/2022
Section Cited

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General. Good physical health of personnel shall be verified by a health screening, including a T.B. test, performed and signed by a physician not more than six months prior to or seven days after employment.
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LPA observed staff did not have a chest X-ray on file. this poses a potential health and safety 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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