502700415-8-1-2022-27-AS-APAA-CGVVNA-20220801163446

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700415
Report Date: 08/01/2022
Date Signed: 08/01/2022 04:34:51 PM

Document Has Been Signed on 08/01/2022 04:34 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:	DIGNICARE LIVING LLC		FACILITY NUMBER:	502700415
ADMINISTRATOR:	EVANGELIO, JR, NAPOLEON		FACILITY TYPE:	740
ADDRESS:	3100 DOVEHOUSE LN		TELEPHONE:	(209) 551-0787
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	6	CENSUS: 5	DATE:	08/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Marissa Baisas		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	Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility on 08/01/2022 at 10:00am to conducted an unannounced annual visit. LPA Pascua was greeted by caregiver, Marissa Baisas and stated the purpose for today's visit. Caregiver, Baisas was asked to call the Facility Designated Administrator to let them know that CCL was present at this time. There was two other staff members present, Teresita Lim and Lyn Testmio. This facility holds a hospice waiver for 2. Census was currently 5. A tour of this facility was conducted with caregiver, Baisas. Administrator holds current certificate and expires on, 03/09/2024. The facility has a main entrance COVID screening point. The facility has a 30 day supply of PPE. The facility conducts disinfecting cleaning daily. Fire extinguisher located in the laundry room appeared to have been annually inspected on 07/07/2022. The kitchen area was toured. LPA Pascua observed a sufficient seven days of non-perishable as well as two days worth of perishable food supplies in the main kitchen. Additional perishable supplies were identified in an additional freezer located in the garage. Knives and additional cleaning supplies were locked and made inaccessible to the residents at this time. LPA Pascua observed a locked centralized stored medication cabinet located in the kitchen. Along with Caregiver, Baisas, the LPA observed, reviewed, and compared resident medication with the medication dispensing logs. First Aid Kit was present and contained all of the required components. Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time. Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. A tour of the garage was conducted. Additional storage for supplies were stored in cabinets. All additional cleaning supplies were locked and made inaccessible to the residents at this time. A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time. A tour of the staff bedroom was also conducted.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DIGNICARE LIVING LLC	FACILITY NUMBER: 502700415
	VISIT DATE: 08/01/2022

NARRATIVE

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A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. Grab bars were present and were in good repair at this time.

A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time. Additional incontinence supplies were also identified.

The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL.

-LIC308

-LIC 400

-LIC 500

-LIC 610.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to the Title 22 Rules and Regulations, Health and Safety Code.

Appeal rights were printed and a copy of this report was given to caregiver, Marissa Baisas.

Exit Interview.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/01/2022 04:34 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: DIGNICARE LIVING LLC	FACILITY NUMBER: 502700415
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

87303(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited since the window screens were not present and residents may not open their windows without pests entering the facility, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2022
	Plan of Correction
1 2 3 4	Licensee agrees to replace broken window screens throughout the facility and send in a picture to LPAs email by the end of business on 08/08/2022.

Type B

Section Cited

CCR

87303(a)

87303 Maintanence and Operations (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above by LPA observed turning knobs to the gas stove to be broken or melted off, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2022
	Plan of Correction
1 2 3 4	Licensee agrees to fix and replace gas stove knobs and send in a picture to the LPAs by the end of business on 08/08/2022.

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) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC809 (FAS) - (06/04)

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