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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
502700517
Report Date:
08/29/2022
Date Signed:
09/06/2022 10:45:30 AM
Document Has Been Signed on
09/06/2022 10:45 AM
- 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 II
FACILITY NUMBER:
502700517
ADMINISTRATOR:
KAHLON, HARDEEP
FACILITY TYPE:
740
ADDRESS:
1020 JAYHAWK WAY
TELEPHONE:
(209) 523-0124
CITY:
MODESTO
STATE:
CA
ZIP CODE:
95358
CAPACITY:
6
CENSUS:
5
DATE:
08/29/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:30 AM
MET WITH:
Kashmindar Kaur
TIME COMPLETED:
12:30 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 08/29/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Kashmindar Kaur, who was briefly interviewed. It was learned that there was (1) resident under the care of hospice at this time while (3) other residents were receiving services through home health.
This facility does have a hospice waiver for (6) residents and fire cleared for (1) bedridden resident at any given time.
Current census was 5 residents.
A tour of this facility was conducted alongside the facility designated Administrator Kashmindar Kaur.
Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Kashmindar Kaur.
Kitchen area was toured. Cabinets and drawers were reviewed.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time in the garage area.
A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinet, located in the kitchen area, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator. This medication cabinet was observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restroom was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperature was taken and measured to make sure that it was within the allowed range of 105-120 degrees.
Linen closet, located in the entry way, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
SUPERVISOR'S NAME:
Stephenie Doub
TELEPHONE:
(916) 263-2131
LICENSING EVALUATOR NAME:
Charlie Yang
TELEPHONE:
(916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE:
08/29/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/29/2022
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
6
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:
KIND CARE HOME II
FACILITY NUMBER:
502700517
VISIT DATE:
08/29/2022
NARRATIVE
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Garage area was toured. This area was used to house additional furniture and supplies for the facility residents. Wheelchairs and additional beds were observed to be present.
Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguisher, located in dining area, was observed to have been annually inspected on 05/23/2022 by the local fire extinguisher company, Jorgensen, and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.
The following forms and documents were requested to be updated and submitted into CCL:
LIC 308
LIC 400
LIC 500
LIC 610
The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.
Appeal rights were printed and a copy was given to the facility designated Administrator Sandra Jackson at this time.
Exit Interview
SUPERVISOR'S NAME:
Stephenie Doub
TELEPHONE:
(916) 263-2131
LICENSING EVALUATOR NAME:
Charlie Yang
TELEPHONE:
(916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE:
08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/29/2022
LIC809
(FAS) - (06/04)
Page:
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of
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Document Has Been Signed on
09/06/2022 10:45 AM
- 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:
KIND CARE HOME II
FACILITY NUMBER:
502700517
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/29/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the hot water temperatures measured in the facility restrooms were at 121.2 degrees which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/30/2022
Plan of Correction
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Facility designated Administrator stated that the hot water heater will be turned down and the hot water will be measured for the next 24 hours and monitored. A statement of correction, along with readings for the past 24 hours of proper hot water temperatures, will be completed and submitted into CCL by the due date of 08/30/2022.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above since it was discovered that cleaning supplies were accessible to residents and care under the kitchen sink and resident restroom which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/30/2022
Plan of Correction
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Facility designated Administrator stated that the cleaners and all supplies will be removed and stored in a cabinet to make them inaccessible to the residents at all times. A statement of correction, along with photos of the repaired kitchen sink cabinet, will be completed and submitted into CCL by the due date of 08/30/2022.
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:
Charlie Yang
TELEPHONE:
(916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE:
08/29/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/29/2022
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
09/06/2022 10:45 AM
- 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:
KIND CARE HOME II
FACILITY NUMBER:
502700517
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/29/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.2(a)(7)
Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (7) To fully participate in planning their care, including the right to attend and participate in meetings or communications regarding care and services to be provided, according to Health and Safety Code section 1569.80 and involve persons of their choice in this planning. The licensee shall provide necessary information and support to ensure that residents direct the planning of their care to the maximum extent possible, and are enabled to make informed decisions and choices.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in that the facility kitchen refrigerator was observed to be locked with a metal cord that would not allow access to the residents which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/30/2022
Plan of Correction
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Facility designated Administrator stated that the locking mechanism on the refrigerator will be removed. A statement of correction, along with photos of the locking mechanism no longer being present, will be completed and submitted into CCL by the due date of 08/30/2022.
General Food Service Requirements
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:
Charlie Yang
TELEPHONE:
(916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE:
08/29/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/29/2022
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
09/06/2022 10:45 AM
- 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:
KIND CARE HOME II
FACILITY NUMBER:
502700517
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/29/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87204(b)
Limitations -Capacity and Ambulatory Status
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in that one of the resident bedrooms had been converted into a retreat style room for employees and board members visiting out of town or serving as an office space which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/05/2022
Plan of Correction
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Facility designated Administrator stated that the resident bedroom will no longer be utilized as a retreat style room for employees and board members and be converted back to the original licensed room designation. A statement of correction will be completed and submitted into CCL by the due date of 09/05/2022.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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:
Stephenie Doub
TELEPHONE:
(916) 263-2131
LICENSING EVALUATOR NAME:
Charlie Yang
TELEPHONE:
(916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE:
08/29/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/29/2022
LIC809
(FAS) - (06/04)
Page:
5
of
6
Document Has Been Signed on
09/06/2022 10:45 AM
- 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:
KIND CARE HOME II
FACILITY NUMBER:
502700517
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/29/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(f)(2)(C)
Other Provisions
(f) A facility shall have both of the following in place: (2) A set of keys available to facility staff on each shift for use during an evacuation that provides access to all of the following: (C) All facility exit doors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above since facility exits were equipped with high locking mechanisms and cord locks on the facility driveway fence which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/30/2022
Plan of Correction
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3
4
Facility designated Administrator stated that the high locking mechanisms on all of the doors will be removed, as well as, the chain lock on the driveway gate. A statement of correction, along with photos of all locks being removed, will be completed and submitted into CCL by the due date of 08/30/2022.
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:
Stephenie Doub
TELEPHONE:
(916) 263-2131
LICENSING EVALUATOR NAME:
Charlie Yang
TELEPHONE:
(916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE:
08/29/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/29/2022
LIC809
(FAS) - (06/04)
Page:
6
of
6