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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700517
Report Date: 08/17/2021
Date Signed: 08/17/2021 04:47:53 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/17/2021 04:47 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:KIND CARE HOME IIFACILITY NUMBER:
502700517
ADMINISTRATOR:KAHLON, HARDEEPFACILITY TYPE:
740
ADDRESS:1020 JAYHAWK WAYTELEPHONE:
(209) 523-0124
CITY:MODESTOSTATE: CAZIP CODE:
95358
CAPACITY: 6CENSUS: 4DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Maninderdeep KahlonTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Maninderdeep Kahlon and explained the purpose of the visit.

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 108.5 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. During the inspection in the kitchen LPA and Administrator observed medications (comfort packs for three residents on hospice) unlocked in the refrigerator. LPA also observed medication errors in the medication administration record for 2 of 2 records reviewed. The facility did not have discontinued medication documentation for R1 from the doctor.

LPA reviewed 3 resident and 2 staff files, including criminal record clearances. All staff are fingerprint cleared, however, S1 was not associated to the facility. Fire drill was completed on 8/2/2021.

Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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 08/17/2021 04:47 PM - It Cannot Be Edited


Created By: Albert Johnson On 08/17/2021 at 02:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: KIND CARE HOME II
FACILITY NUMBER: 502700517

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2021
Section Cited

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(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication re-evaluation.
(2) Once ordered by the physician the medication is given according to the physician's directions.
(3) A record of each dose is maintained in the resident's record.
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The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. LPA observed medication errors in the medication administration record for 2 of 2 records reviewed. The facility did not have discontinued medication documentation for R1 from the doctor.
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The facility will also update the appraisal/needs and service plan for R1 and R2. Please provide this information to CCL by 8/18/2021. If you need additional time please request by email or by a phone call.
Type A
08/18/2021
Section Cited

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Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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This requirement is not met as evidenced by: LPA and Administrator observed medications (comfort packs for three residents on hospice) unlocked in the refrigerator that were accessible to the residents in care. This poses an immediate health and safety risk to the 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 Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021


LIC809 (FAS) - (06/04)
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