<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700342
Report Date: 11/23/2022
Date Signed: 11/27/2022 09:33:52 PM


Document Has Been Signed on 11/27/2022 09:33 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
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:
11/23/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Jeanna PaittanTIME COMPLETED:
02:30 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
LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the annual visit conducted on 11/07/2022 .

Deficiency cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POCs by POC due date.

Facility was provided a POC cleared letter for cleared citations.

During the tour of the facility LPA observed (photo taken) that the facility is using the garage as a bedroom, LPA reviewed the facility sketch and confirmed that the Fire Marshal did not clear the garage to be used as a staff room or a bedroom. The Administrator will be moving out on the 1st of December 2022.

R1 currently has medication in the facility that does not have a current order from a primary care physician. The facility received medication with no orders from the family of R1 on 11/09/2022 with a change from the 100 mg of Amiodarone to 200 mg (RX#387) without a prescription from R1's Physician.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022
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 11/27/2022 09:33 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
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: 11/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/24/2022
Section Cited

1
2
3
4
5
6
7
Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
8
9
10
11
12
13
14
 LPA observed that the facility is using the garage as a bedroom, LPA reviewed the facility sketch and confirmed that the Fire Marshal did not clear the garage to be used as a staff room or a bedroom. This poses an immediate health and safety risk.
8
9
10
11
12
13
14
Administrator shall submit a Statement of Understanding regarding the regulations pertaining to fire safety by POC date 11/24/2022.

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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022
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
VISIT DATE: 11/23/2022
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
A meeting has been scheduled in the Sacramento Regional Office on 11/30/2022 at 10:30am.

As the Licensee, your attendance at this meeting is mandatory.

Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Civil penalties assessed


Exit interview conducted

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3