502700581-5-4-2023-27-AS-APAA-CRHRE6-20230504125701

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700581
Report Date: 05/04/2023
Date Signed: 05/04/2023 12:57:18 PM

Document Has Been Signed on 05/04/2023 12:57 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:	GATE OF BEAUTIFUL II, THE		FACILITY NUMBER:	502700581
ADMINISTRATOR:	NICOLE ELL		FACILITY TYPE:	740
ADDRESS:	3300 SHARON AVE		TELEPHONE:	(209) 526-2425
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	6	CENSUS: 3	DATE:	05/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Sarena Arias		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/04/02023 at 10:30am, Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct an annual visit. LPA was greeted by Facility Designated Representative (FDR), Sarena Arias and explained the purpose of the visit. LPA asked the FDR Arias call the Facility Designated Administrator to inform them that CCL was present at this time. This facility is licensed to served 6 residents, all of whom may be non-ambulatory. This facility also has a dementia plan on file and has a current hospice waiver for 6. Current census was 3. 2 out of 3 residents were out of the facility at the time of the visit. LPA reviewed 3 resident files. LPA reviewed 4 staff files. 4 out of 4 staff files were complete and up to date. Facility Designated Administrator currently holds an active and current administrator certificate #6019506740 and expires on 08/16/2024. LPA initiated a tour with FDA Arias. The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by A.R.F. Fire Extinguisher Co and is valid until 08/26/2023.. The kitchen area was toured. LPA observed a suppy of 7 day non-perishable and 2-day perishable foods in the cabinets and refrigerator. Additional perishable food supplies were identified in the garage. LPA observed cleaning supplies under the kitchen counter and was not locked and made inaccessible to the residents in care. LPA reminded FDR Arias that all toxins and cleaning supplies need to be locked and made inaccessible. LPA observed a locked centralized stored medication cabinet located in the laundry room. Along with the FDR, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components. LPA observed a large red bottle of pain medication that did not have a prescription order on it. After an interview with FDR Arias was conducted it was learned that the pain medication was given by a family member. LPA informed FDR Arias that all medication needed to have a prescription order along with a label with the resident's name. Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GATE OF BEAUTIFUL II, THE	FACILITY NUMBER: 502700581
	VISIT DATE: 05/04/2023

NARRATIVE

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A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.

A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.

Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

A tour of the garage was conducted. Additional perishable food supplies were identified.

The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

-Liability Insurance

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations.

An Exit interview was conducted, a copy of the 809, 809-C, 809-D and appeals rights were provided to the facility at the end of this visit.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/04/2023 12:57 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GATE OF BEAUTIFUL II, THE	FACILITY NUMBER: 502700581
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 by not locking disinfectants, cleaning solutions, poisons, and other items which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2023
	Plan of Correction
1 2 3 4	While discussing deficiency with the licensee locked disinfectants and made them inaccessible to the residents at this time while LPA was present.

Type A

Section Cited

CCR

87611(d)

(b) The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following: 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 above in not providing a proper care plan for R1. It was reviewed that R1 has a foley catheter upon admission but does not have a care plan on file. This poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 05/05/2023
	Plan of Correction
1 2 3 4	Facility Administrator stated that a review of the section, 87611(d), will be conducted. A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov by the due date of 05/05/2023 COB at 5:00pm. Information submitted must include attendees, trainers, and information discussed. In addition, Facility Administrator shall provide a copy of the care plan to the LPA to the LPA's email by 05/05/2023.

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	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/04/2023 12:57 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GATE OF BEAUTIFUL II, THE	FACILITY NUMBER: 502700581
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(e)

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and file review, the Licensee did not ensure R1's over the counter pain medication had a prescription label on the medication. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	Facility staff agrees to conduct medication training for all staff by POC Date: 05/25/2023. Facility staff agrees to email training documents to LPA by 05/25/2023. Facility staff agrees to send a picture of the prescription label on the medication the LPA's email by 05/25/2023.

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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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