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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700543
Report Date: 08/24/2021
Date Signed: 08/24/2021 04:31:55 PM

Document Has Been Signed on 08/24/2021 04:31 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:AG ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
502700543
ADMINISTRATOR:NKWOCHA, ONYEMAFACILITY TYPE:
735
ADDRESS:3829 WILD PALMS DRTELEPHONE:
(209) 275-3272
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 4CENSUS: 4DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Augusta Nkwocha, LicenseeTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA met with Augusta Nkwocha, Licensee (AD).

LPA and AD, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas.
Hot water temperature measured 114.4 degrees in residents bathroom with the AD which is in required range of 105 to 120 degrees.

Last Fire Drill conduced 5/8/21. Fire extinguishers maintained 5/3/2021. Fire alarm and carbon monoxide functional. First Aid pack complete. Emergency contact information updated 3/21/2021. LPA and AD observed centrally stored medications.

LPA reviewed 4 staff and 4 resident files. Resident emergency contact complete. LPA reviewed staff files. S1 was missing TB test and proof of health screen .
Administrator Certificate valid until 6/24/2023.

All persons in facility fully vaccinated with exception of 1 resident due to personal reasons. LPA observed practicing social distancing. LPA observed 30 days PPE supply.

809 Cont. >>>>>>>>>>>>>>>>>>>
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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 08/24/2021 04:31 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 08/24/2021 at 12:32 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: AG ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 502700543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2021
Section Cited

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 80065 Personnel Requirements (g) All personnel, including the licensee, administrator and volunteers, shall be in good health, and shall be physically, mentally, and occupationally capable of performing assigned tasks.

(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

(2) A health screening report signed by the person performing such screening shall be made on each person specified above, and shall indicate the following:

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This requirement is not met as evidenced by based on records reviewed, one employee did not have proof of TB test or health screen on file. Licensee did not retain proof that a health screening, including a test for tuberculosis was performed by or under the supervision of a physician not more than one year prior to or seven days after employment. This is a potential risk to clients.
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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:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021


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: AG ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 502700543
VISIT DATE: 08/24/2021
NARRATIVE
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LPA observed walkways to exits free and clear of debris. LPA observed furniture and grounds in good, clean condition.

LPA observed client activity calendar posted and activities available to residents.

LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies. LPA observed sharps and toxins locked.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC809 (FAS) - (06/04)
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