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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700553
Report Date: 06/04/2021
Date Signed: 06/04/2021 10:12:55 AM

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:EDITHS HOME CAREFACILITY NUMBER:
502700553
ADMINISTRATOR:RODRIGUEZ, EDITHFACILITY TYPE:
740
ADDRESS:3536 HALLSBORO CTTELEPHONE:
(209) 567-2423
CITY:MODESTOSTATE: CAZIP CODE:
95357
CAPACITY:6CENSUS: 5DATE:
06/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Edith Rodriguez, AdminstratorTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analysts (LPA's) Sarah Hurt and Ruth Wallace made an unannounced visit on this day for the purpose of conducting a Required - 1 Year Evaluation. LPA's met with Administrator. Administrator's Certificate which expires 02/15/2023

LPA's toured the facility grounds with Administrator. LPA's inspected 4 resident bedrooms. Bathrooms and hand washing areas were observed clean and sanitary. Non-slip textured surfaces were observed in shower. Water temperature measured at 106.0 F. Smoke detectors observed operational. The facility also has sprinkler system. Fire extinguishers were observed mounted and expires 10/01/2021. The facility was at a comfortable temperature for residents in care. LPA's observed required postings in prominent area for residents to view. LPA's reviewed food services and observed enough food on hand to meet the 2 day perishable, 7 day non-perishable requirement. Medication administration was observed with no concerns noted. Medications were centrally stored and inaccessible to persons in care.
LPA's requested to review 5 resident files. Items reviewed but not limited to were: admission's agreement, Physician's reports, Needs and Services plans and TB tests, with no concerns noted.
LPA's requested to review 3 staff files. Items reviewed but not limited to were health screening, TB test and Fingerprint Clearance as well as annual training. Aministrator is missing current First Aid/CPR/AED certificate.
LPA reviewed emergency preparedness procedures with no concerns noted. Administrator reported that, the generator is tested monthly.
LPA requested the following documents to be submitted within one week of annual visit: LIC 308 and LIC 500.

Based on LPA's observations, the facility appears not to be in substantial compliance with Title 22 Division 6 of the California Code of regulations. Deficiency cited on 809-D.
An exit interview was conducted with Administrator and a copy of this report and 809-D, appeal rights, and confidential list of staff and resident files reviewed were provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
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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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: EDITHS HOME CARE
FACILITY NUMBER: 502700553
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/11/2021
Section Cited

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All RCFE staff who assist residents with personal activities of daily living shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter.
(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:

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Based on LPA's observation, the licensee did not comply with the section cited above because S1 was missing current First Aid Certificate which poses an potential health, safety or personal rights risk to persons 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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2021
LIC809 (FAS) - (06/04)
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