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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700990
Report Date: 01/27/2022
Date Signed: 01/27/2022 12:24:37 PM

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:VENEMAN CARE HOMEFACILITY NUMBER:
502700990
ADMINISTRATOR:RAMIT, LOLITAFACILITY TYPE:
740
ADDRESS:3605 NORTHAMPTON LANETELEPHONE:
(209) 623-7844
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 5DATE:
01/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lolita Ramit - AdministratorTIME COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace contacted the facility before visit to conduct a 1 Year Annual Inspection due to COVID-19 and pre-cautionary measures. LPA Wallace identified herself and discussed the purpose of the visit with Administrator.

LPA Wallace inspected the interior and exterior of the facility with Administrator during the visit.

Resident's room were furnished, and sanitary. There are two shared rooms and two private rooms. The laundry room has locked cabinets for cleaning supplies. The living room is furnished and has space for activities. The facility has a pool, which is enclosed. There is a unlocked fence around the pool. The facility has an exterior emergency exit gate. The licensee will keep all current facility files and medication procedures in place.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. The kitchen was clean. Hot water temperature was measured at (109.3) degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguishers expires 01/05/2022. LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to residents. LPA reviewed staff associations to the facility. First aid kit was checked and is complete.



Deficiencies are cited from California Code of regulations, Title 22, Division 6, 8 and citation is listed on the attached LIC 809-D. Two Immediate Civil Penalty Assessed of $500.00 each.

An exit interview was conducted with Administrator. Copies of reports, appeal rights, and civil penalty was left at the facility..

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
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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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: VENEMAN CARE HOME
FACILITY NUMBER: 502700990
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(e)
Personal Accommodations and Services
(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation (pool gate unlocked surrounding pool), the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2022
Plan of Correction
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Licensee agreed to lock up pool gate while LPA observed during the physical plant inspection on today's day. Immediate Civil Penalty assessed of $500.00. No further action required.
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation (The fire extinguishers tags expired 1/5/2022), the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2022
Plan of Correction
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Licensee agreed to purchase new fire extinguisher while LPA was at facility on today's date. Immediate Civil Penalty assessed of $500.00. No further action required.
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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022
LIC809 (FAS) - (06/04)
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