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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
502700517
Report Date:
08/16/2023
Date Signed:
08/29/2023 09:56:04 AM
Document Has Been Signed on
08/29/2023 09:56 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
SACRAMENTO AC/SC
,
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:
4
DATE:
08/16/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:00 AM
MET WITH:
Kashmindar Kaur
TIME COMPLETED:
01:30 PM
NARRATIVE
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Unannounced annual licensing visit made out to this facility on 08/16/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Davina Bratton, who was briefly interviewed. This LPA requested that the facility caregiver go ahead and contact the facility designated Administrator, Kashmindar Kaur, to inform her that CCL was present at this time. The facility designated Administrator, Kashmindar Kaur, arrived shortly thereafter to this facility. A brief interview was conducted with the facility designated Administrator at this time.
This facility is licensed to serve and accept up to 6 residents who are deemed to be ambulatory and non ambulatory. This facility is not vendorized to accept and retain any Regional Center residents at this time.
Current census was 4 residents. It was learned that there were (2) residents currently on hospice. There were (2) dementia diagnosed residents and (3) residents with bowel/bladder incontinence.
Tour of this facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed. Drawers and cabinets housing cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Drawers containing knives and other cutlery were observed to be locked and made inaccessible to the residents at this time.
Food supply was reviewed for 2-day perishable and 7-day nonperishable food quantities at this time. Additional nonperishable food items were observed to be stored in the garage area along with an additional refrigerator unit.
Dining room, living area, and all other areas designated for resident use were observed to be maintained and observed to be in compliance at this time.
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be present and maintained in compliance at this time.
A tour of the resident restrooms was conducted. Shower areas, toilets, and wash basins were reviewed and observed to be functional and in good repair at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of
SUPERVISOR'S NAME:
Liza King
TELEPHONE:
(916) 263-4752
LICENSING EVALUATOR NAME:
Charlie Yang
TELEPHONE:
(916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
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
7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC
,
2525 NATOMAS PARK DR. STE.270
SACRAMENTO
,
CA
95833
FACILITY NAME:
KIND CARE HOME II
FACILITY NUMBER:
502700517
VISIT DATE:
08/16/2023
NARRATIVE
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105-120 degrees.
Medication for resident use, located in kitchen cabinet, was reviewed. Policies and procedures for dispensing, handling, and overall documentation of the resident medications were discussed with the facility designated Administrator at this time.
Fire extinguishers were observed to be placed throughout this facility and were annually inspected on 05/02/2023 from the local fire extinguisher company, Jorgensen Co, and in compliance at this time.
First aid kit was observed to be present and contained all of the required components at this time.
Linen closet, located in facility hallway, was observed to contain a sufficient supply of blankets, sheets, and towels for resident use.
Laundry area, located adjacent to kitchen area, was observed to be made inaccessible to the residents at this time. Laundry detergents, bleach, and all other cleaning supplies were observed to be stored in cabinets where they were locked and made inaccessible to the residents at this time.
Exterior grounds of this facility was toured. Facility perimeter fence, side gates, and emergency exits were reviewed.
Additional garage space was reviewed and observed to be contain materials and items intended for upkeep and maintenance of this facility.
A review of (5) facility personnel files was conducted.
A review of (4) facility resident files was conducted.
The following forms 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 Codes.
Appeal rights were printed and a copy was given to the facility designated Administrator at this time.
Exit Interview
SUPERVISOR'S NAME:
Liza King
TELEPHONE:
(916) 263-4752
LICENSING EVALUATOR NAME:
Charlie Yang
TELEPHONE:
(916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
LIC809
(FAS) - (06/04)
Page:
2
of
7
Document Has Been Signed on
08/29/2023 09:56 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
SACRAMENTO AC/SC
,
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:
08/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
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 there were no carbon monoxide detectors installed or present at this time which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/17/2023
Plan of Correction
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2
3
4
The facility designated Administrator stated that a carbon monoxide will be installed, in accordance with Chapter 8 (commencing with Section 13260) of Part 2 of Division 12, with a statement of correction, along with photos of the installed carbon monoxide detector(s), to be submitted into CCL by the due date.
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in [2] out of [5} personnel records were incomplete missing required health screening forms with current TB clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/17/2023
Plan of Correction
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2
3
4
The facility designated Administrator stated that all facility personnel will receive a current health screening and be properly cleared for TB with certified results. A statement of correction will be completed, along with copies of the health screening forms and documents, to be submitted into CCL by the due date.
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:
Liza King
TELEPHONE:
(916) 263-4752
LICENSING EVALUATOR NAME:
Charlie Yang
TELEPHONE:
(916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
08/29/2023 09:56 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
SACRAMENTO AC/SC
,
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:
08/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in [4] out of [5] facility personnel were not properly associated to this facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/17/2023
Plan of Correction
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The facility designated Administrator stated that all facility personnel will be properly fingerprint cleared and associated prior to employment at this facility. A statement of correction, along with copies of the proper fingerprint transfers of all facility personnel, will be completed and submitted into CCL by the due date.
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review,, the licensee did not comply with the section cited above in [1] out of [5] facility personnel was not currently certified for First Aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/17/2023
Plan of Correction
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The facility designated Administrator stated that all facility personnel will be properly trained and certified in First Aid. A statement of correction, along with copies of the updated and current First Aid training of all facility personnel, will be completed and submitted into CCL by the due date.
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:
Liza King
TELEPHONE:
(916) 263-4752
LICENSING EVALUATOR NAME:
Charlie Yang
TELEPHONE:
(916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
LIC809
(FAS) - (06/04)
Page:
4
of
7
Document Has Been Signed on
08/29/2023 09:56 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
SACRAMENTO AC/SC
,
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:
08/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in [1] out of [4] resident files was missing the required medical assessment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/17/2023
Plan of Correction
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The facility designated Administrator stated that all facility residents will receive a current medical assessment and be properly cleared for TB with certified results. A statement of correction will be completed, along with copies of the medical assessment forms and documents, to be submitted into CCL by the due date.
Section Cited
Deficient Practice Statement
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2
3
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:
Liza King
TELEPHONE:
(916) 263-4752
LICENSING EVALUATOR NAME:
Charlie Yang
TELEPHONE:
(916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
LIC809
(FAS) - (06/04)
Page:
5
of
7
Document Has Been Signed on
08/29/2023 09:56 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
SACRAMENTO AC/SC
,
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:
08/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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 since there was a crack in the sliding closet mirror doors in a resident bedroom and unused mattresses and furniture in the facility garage which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/23/2023
Plan of Correction
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2
3
4
The facility designated Administrator stated that the closet doors will be repaired/replaced and the facility garage will be clean and cleared of any unused mattresses and furniture. A statement of correction will be completed, along with photos of the repaired/replaced closet mirro doors and cleaned out garage, to be submitted into CCL by the due date.
Section Cited
Personnel Records
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
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:
Liza King
TELEPHONE:
(916) 263-4752
LICENSING EVALUATOR NAME:
Charlie Yang
TELEPHONE:
(916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
LIC809
(FAS) - (06/04)
Page:
6
of
7
Document Has Been Signed on
08/29/2023 09:56 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
SACRAMENTO AC/SC
,
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:
08/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Records
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.
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 the section cited above in [3] out of [4] resident records were missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/23/2023
Plan of Correction
1
2
3
4
The facility designated Administrator stated that all facility resident records will be updated to contain all required forms and documents. A statement of correction will be completed, along with copies of the updated form and documents, to be submitted into CCL by the due date.
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:
Liza King
TELEPHONE:
(916) 263-4752
LICENSING EVALUATOR NAME:
Charlie Yang
TELEPHONE:
(916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
08/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/16/2023
LIC809
(FAS) - (06/04)
Page:
7
of
7