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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700415
Report Date: 08/06/2021
Date Signed: 08/11/2021 10:41:26 AM

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:DIGNICARE LIVING LLCFACILITY NUMBER:
502700415
ADMINISTRATOR:EVANGELIO, JR, NAPOLEONFACILITY TYPE:
740
ADDRESS:3100 DOVEHOUSE LNTELEPHONE:
(209) 551-0787
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 6DATE:
08/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marissa Raisas, Caregiver.TIME COMPLETED:
02:00 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
Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA was greeted by Marissa Raisas, Caregiver (S1). LPA met with Napolean Evangelio, Administrator (AD). AD recently underwent surgery. LPA met completed the inspection with S1. LPA reviewed and received the updated Liability Insurance which meets the requirements. LPA observed Administrator certificate current and valid until 3/9/2022.

LPA and S1 inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, laundry room, and dining room area. LPA observed sufficient seven days non-perishable and two days perishable food supplies in the main kitchen. LPA and S1 observed centrally stored medications and reviewed the MAR for accuracy and completion. Hot water temperature was measured in residents' bathroom with S1 and measured at 120 degrees. LPAs observed the Carbon Monoxide monitor in facility was not functioning. LPA observed fire alarm functioning. LPA verified there was no FireDrill log. S1 stated they conducted the fire drill in November 2020. LPA observed fire extinguishers serviced on 5/5/21. LPA observed first aid kit complete.

Cont on 809-C >>>>>>>>>>>>>>>>>>>>>>>
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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 5
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: DIGNICARE LIVING LLC
FACILITY NUMBER: 502700415
VISIT DATE: 08/06/2021
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
LPAs observed cabinet under sink in kitchen locked. LPA observed cabinet in laundry room and cabinet undersink in bathroom where toxins stored unlocked.

Staff and visitors enter the facility through ringing the locked front door, sanitizer and thermometer were observed. COVID signs posted in front entry way or throughout the facility. LPA observed masks and hand sanitizer available to visitors.

Sign in sheets were observed to document date, visitors name, and temperature. Sign in sheets did not include symptom screening for reporting requirements to public health officer and contact tracing.

LPA reviewed 3 staff files and 6 resident files. While reviewing files, LPA observed all staff are vaccinated and have TB/Health Screen completed.. 5 of 6 residents vaccinated. One resident has chosen not to get vaccinated due to personal reasons. All residents files completed. All resident files have emergency contact information.

LPA observed hospital bed in R1 and R2 rooms. S1 confirmed R1 and R2 are not on hospice. LPA reviewed R1 and R2 file and found no doctors note issuing the use of a hospital bed.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with Marissa Raisas, Caregiver. and a copy of report will be email Napolean Evangelio, Administrator (AD).
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: DIGNICARE LIVING LLC
FACILITY NUMBER: 502700415
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2021
Section Cited

1
2
3
4
5
6
7
Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
8
9
10
11
12
13
14
This requirement was not met as evidenced by based on LPA observation, the licensee did not have a functioning Carbon Monoxide on site. This poses an immediate health and safety risk to clients in care.
8
9
10
11
12
13
14
Type A
08/07/2021
Section Cited

1
2
3
4
5
6
7
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.
8
9
10
11
12
13
14
This requirement has not been met as evidence by LPA observed unlocked toxins in laundry room and resident’s bathroom. This poses an immediate health to residents in care
8
9
10
11
12
13
14
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: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: DIGNICARE LIVING LLC
FACILITY NUMBER: 502700415
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2021
Section Cited

1
2
3
4
5
6
7
Care of Persons with Dementia. Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
8
9
10
11
12
13
14
This requirement was not met as evidenced by records reviewed, facility did not have record of fire Drill log. Caregiver stated Nov 2020 but could not confirm which is also over the 3 month period. Licensee had no record to provide to LPA. LPA was unable to determine when the last disaster drill was conducted as required. This poses a potential safety risk to the residents in care.
8
9
10
11
12
13
14
Type B
08/16/2021
Section Cited

1
2
3
4
5
6
7
87464 (f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).
(As identified in 87101: (E) Maintenance of house rules for the protection of residents)
8
9
10
11
12
13
14
This regulation was not met by evidence by: A sign-in policy was not enacted with all visitors to ensure compliance with central entry point for symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing).
8
9
10
11
12
13
14
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: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: DIGNICARE LIVING LLC
FACILITY NUMBER: 502700415
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2021
Section Cited

1
2
3
4
5
6
7
87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.

(1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.
8
9
10
11
12
13
14
LPA observed hospital bed in R1 and R2 rooms. S1 confirmed R1 and R2 are not on hospice.
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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5