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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700701
Report Date: 10/24/2022
Date Signed: 10/25/2022 08:21:08 AM

Document Has Been Signed on 10/25/2022 08:21 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ASIANA RESIDENTIAL SERVICESFACILITY NUMBER:
502700701
ADMINISTRATOR:KHAN, SAJIDAFACILITY TYPE:
735
ADDRESS:5020 TAMARA WAYTELEPHONE:
(209) 566-3933
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY: 6CENSUS: 6DATE:
10/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Evangeline Majidi
Saria Anjuman		TIME COMPLETED:
03:03 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Staff and explained the purpose of the visit. LPA was tested for mitigation risk according to the plan submitted, also noted that Staff had on mask during today's visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 110 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. The facility will get updated IPP for all residents in care by 11/15/2022 (Advisory Given). LPA reviewed 4 resident and 3 staff files, including criminal record clearances. Fire drill was completed on 9/23/22. During the medication review LPA observed medication not in their original containers pre-poured for all residents in care.

All staff are Fingerprint cleared and associated to the facility. The facility will get updated I.D.'s for S1 and S2 by 11/15/22. (Advisory Given)

Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
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 10/25/2022 08:21 AM - It Cannot Be Edited


Created By: Albert Johnson On 10/24/2022 at 02:27 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: ASIANA RESIDENTIAL SERVICES
FACILITY NUMBER: 502700701

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2022
Section Cited
CCR
80075(k)(5)

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80075(k)(5) Health Related Services. Each client's medication shall be stored in its originally received container. This requirement was not met as evidenced by observation, LPA and Staff observed pre-poured medication for all residents
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The Administrator shall submit a plan of how the facility will dispense medications to clients on daily basis. All facility staff who manage,
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This posed a potential health and safety risk to resident’s in care.
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store and dispense medication shall attend an in-service medication training. Training certificate shall be submitted to Licensing by 10/28/2022

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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:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022


LIC809 (FAS) - (06/04)
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