502700415-8-6-2024-27-AS-APAA-D7W2KU-20240806172832

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700415
Report Date: 08/06/2024
Date Signed: 08/06/2024 05:28:44 PM

Document Has Been Signed on 08/06/2024 05:28 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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: 4	DATE:	08/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:	Aldrin Basarte		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	On 08/06/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA Pascua was greeted by Staff Member(SM), Teresita Lim and explained the purpose of the visit. LPA asked that SM Lim called the Facility Designated Administrator( FDA) to inform them that CCL was present at this time. LPA was informed that the FDA was unable to come at this time and was to continue the visit with Facility Designated Representative (FDR), Aldrin Basarte. There was one other staff member present, Lorna Capaypangan. This facility is licensed to serve 6 residents, of which all may be non-ambulatory and 1 may be bedridden. This facility also has a hospice waiver for 4 and has a dementia program on file. LPA reviewed 4 resident files. 4 out 4 resident files did not have an initial or current needs and services plan. 1 out 4 resident files did not have an updated physicians report. LPA reviewed 4 staff files. 4 out 4 staff files were current and up to date. A tour of the facility was conducted with FDR Basarte. Fire extinguisher located in the laundry room appeared to have been annually inspected and is valid until 07/07/2025. 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 the Facility Designated Representative, the LPA observed, reviewed, and compared resident medication with the medication dispensing logs. It was observed that the medication administered for today was not accounted and signed for. This was remedied during this visit. First Aid Kit was present and contained all of the required components.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

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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Document Has Been Signed on 08/06/2024 05:28 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DIGNICARE LIVING LLC	FACILITY NUMBER: 502700415
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with section cited above in not ensuring the a needs and services plan has been conducted for 4 residents. LPA reviewed 4 residents files and observed that there 4 out 4 resident files did not have a reapprasial on file. This poses a potential health safety and personal rights risks to persons in care.
	POC Due Date: 08/30/2024
	Plan of Correction
1 2 3 4	Licensee shall provide a statement of acknowledgement and correction to the LPA by POC date. Licensee shall conduct a plan to conduct all reapraisals for all residents by POC date. Copies of reappraisals shall be provided to LPA to complete POC.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DIGNICARE LIVING LLC	FACILITY NUMBER: 502700415
	VISIT DATE: 08/06/2024

NARRATIVE

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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.
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.

-LIC 308

-LIC 400

-LIC 500

-LIC 610e.

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.

An exit interview was conducted, a copy of this report along with appeal rights were provided at the end of this visit.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

LIC809 (FAS) - (06/04)

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