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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700553
Report Date: 06/20/2024
Date Signed: 06/20/2024 04:22:42 PM


Document Has Been Signed on 06/20/2024 04:22 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Edith RodriguezTIME COMPLETED:
04:30 PM
NARRATIVE
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On 6/20/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Licensee Edith Rodriguez and explained the purpose of today's visit. The Licensee advised that she anticipates adding an addition to the facility in the near future.

LPA Jensen toured the grounds and observed all paths to be free of obstruction. The window screens were in good repair. There is an outdoor seating area with patio furniture and shaded areas for client use. LPA Jensen toured the interior physical plant. The facility was observed to be sanitary with all furniture in good repair. The bedrooms were observed to have all required items. There is an adequate supply if linens on hand. The bathroom water temperature is in compliance. There is non-skid flooring in the bathing area. LPA Jensen toured the kitchen and determined the facility maintains a 7 day supply of non-perishable food and a 2 day supply of perishable food. The knives, toxins and medications were observed to be locked and inaccessible to residents in care. LPA Jensen observed a variety of activities available including a piano, gardening and various board games. The facility has a first aid kit that was determined to be complete and in compliance. The smoke detector and and carbon monoxide were determined to be in good working order. The facility maintains a generator in the event of a power outage. Fire extinguisher was in compliance. There is emergency lighting, food, and water on site. LPA Jensen reviewed 3 of 3 staff files. The staff files were determined to be complete and in compliance. LPA Jensen reviewed 5 of 6 resident files and observed 4 of 5 LIC 602's to be outdated. LPA Jensen observed 3 of 5 Needs and Service Plans to be outdated. LPA Jensen interviewed 1 staff member who was adequately able to answer all questions asked. LPA Jensen interviewed 2 residents who said they were satisfied with all aspects of care. LPA Jensen requested and received a copy of the current liability insurance, the LIC 500 and LIC 308.

Deficiencies are being cited pursuant to the California Code of Regulations (CCR). Failure to correct deficiencies may result in the assessment of civil penalties. An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 11


Document Has Been Signed on 06/20/2024 04:22 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: EDITHS HOME CARE
FACILITY NUMBER: 502700553

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's review of resident files], the licensee did not comply with the section cited above in 3 out of 5 counts which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
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Licensee agrees to email an attestation that the plan of correction was completed by the Plan of Correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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