502700553-6-9-2023-27-AS-KVIA-CSKSGY-20230607135243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700553
Report Date: 06/07/2023
Date Signed: 06/09/2023 10:28:11 AM

Document Has Been Signed on 06/09/2023 10:28 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:	EDITHS HOME CARE		FACILITY NUMBER:	502700553
ADMINISTRATOR:	RODRIGUEZ, EDITH		FACILITY TYPE:	740
ADDRESS:	3536 HALLSBORO CT		TELEPHONE:	(209) 567-2423
CITY:	MODESTO	STATE: CA	ZIP CODE:	95357
CAPACITY:	6	CENSUS: 6	DATE:	06/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Edith Rodriguez, Licensee/Administrator		TIME COMPLETED:	02:00 PM

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On 06/07/2023 Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced annual inspection to this facility. LPA was met by Edith Rodriguez, Licensee/Administrator (Certificate # 6043273740, expiration 02/15/2023. LPA identified herself and the purpose of the visit upon arrival. A brief interview followed. All required signage was posted. At the time, census was 6, 5 were non-ambulatory, 1 was bedridden and 3 residents receiving hospice services. The facility license was issued for: AGE RANGE 60 AND OVER, TOTAL OF 6. 5 NON-AMBULATORY OF WHICH 1 MAY BE BEDRIDDEN. HOSPICE APPROVED FOR 4. Entrance/exit doors had a functioning delayed egress alert.

The tour began in the kitchen/areas. LPA checked the food supply and found that there were enough groceries for 2 days of perishable and 7 days of non-perishable items at this time. Knives were secured in a locked drawer and chemicals were stored in a locked closet and separate from the food supply. Kitchen displayed lidded trash can. LPA observed a sample menu and activities calendar on the refrigerator. The fire extinguisher was last inspected on 10/03/2022 by A.R.F. Fire Extinguisher Company. Enough smoke and carbon monoxide detectors were present to be in compliance.

The LPA observed the furniture, furnishings and lighting in the kitchen/dining room, living room, and four bedrooms. All were in compliance. The hot water was measured in the hallway bathroom and found to be 111 degrees Fahrenheit, within the range of 105-120 degrees required. LPA observed that the 2 bathrooms in the house had grab bars and bath mats along with paper towels. LPA inspected the linen supply and found it to be sufficient for the residents in care. LPA observed the 4 bedrooms were also in compliance with 1 displaying the required "Oxygen in Use" sign.

The tour progressed to the locked garage, the door displayed a sign that stated "Employees Only." LPA inspected laundry area and second refrigerator where employees stored their meals/snacks.

LPA inspected the medications and CSMDR which were located in a locked cabinet in the kitchen. At this time there were no residents being treated for diabetes and injections were not necessary. All medications and

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023

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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: EDITHS HOME CARE	FACILITY NUMBER: 502700553
	VISIT DATE: 06/07/2023

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were up to date. LPA reviewed storage, dosing, and recording procedures with the facility administrator. First Aid kit was inspected and found to be complete at this time.

LPA completed a records review for 3 staff and 3 residents. LPA offered assistance on what to include on the resident pre-appraisals/needs and services plans for hospice residents as hospice residents may sometimes remain a part of their community for years. LPA otherwise found files to be in compliance at this time.

According to the California Code of Regulations (Title 22, Division 6), the LPA observed the following deficiency listed on the LIC 809 D.

An exit interview was conducted with the Licensee/Administrator, Edith Rodriguez. Copies of the Facility Evaluation Report and Appeal Rights were provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/09/2023 10:28 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: EDITHS HOME CARE	FACILITY NUMBER: 502700553
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

CCR 87303(c) All window screens shall be clean and in good repair. 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 when the LPA observed 3 window screens that needed to be repaired/replaced. (1 of the screens in the sliders off the kitchen had a hole and the 2 screens in the living room were bent and no longer fit their windows.) These broken screens could allow bugs into the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/11/2023
	Plan of Correction
1 2 3 4	Licensee will repair/replace the screens and Licensee will send pictures to kimberly.viarella@dss.ca.gov by 06/11/2023 as proof of correction.

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: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023

LIC809 (FAS) - (06/04)

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