502700990-2-28-2023-27-AS-CYAG-CPGSTM-20230228130947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700990
Report Date: 02/24/2023
Date Signed: 02/28/2023 01:09:56 PM

Document Has Been Signed on 02/28/2023 01:09 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	VENEMAN CARE HOME		FACILITY NUMBER:	502700990
ADMINISTRATOR:	RAMIT, LOLITA		FACILITY TYPE:	740
ADDRESS:	3605 NORTHAMPTON LANE		TELEPHONE:	(209) 623-7844
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	6	CENSUS: 5	DATE:	02/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Lolita Ramit		TIME COMPLETED:	05:30 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	Unannounced annual visit conducted on 02/24/2023 by Licensing Program Analysts (LPAs), Kimberly Viarella and Charlie Yang. LPAs were met by staff member, Floradeliza Manalo, who was informed of the purpose of the visit and instructed to call the facility designated Administrator, Lolita Ramit. Ms. Manalo was interviewed briefly. The designated Facility Administrator's certificate, #6047254740, for Lolita Ramit was set to expire on 02/12/2024. Current census was 5 residents. It was learned that there weren't any residents under the care of hospice or home health at this time. It was learned that all of the residents were diagnosed with dementia. This facility does have an approved dementia program on file at this time. LPAs observed exit alarms on the doors. Fire extinguishers were inspected 01/13/2023 by Assured Fire Extinguisher Company and observed to be in compliance at this time. The kitchen was inspected and all drawers and cabinets were opened. Knives were kept in a locked drawer. There was an adequate supply of 2 day perishable and 7 day non-perishable food supply at this time. LPAs observed toxic chemicals in locked cabinets. Bathrooms were inspected and LPAs observed grab bars and non-skid surfaces. The water temperature was reviewed to ensure it was within the allowed range of 105 to 120 degrees. Resident bedrooms and common areas were inspected and contained sufficient furniture and lighting. The exterior grounds were reviewed. There was an in-ground pool on the grounds surrounded by a locked perimeter fence. There was a decorative housing for the hose. There were no other outbuildings or structures on the exterior grounds. Policies and procedures for medication management were discussed with the designated facility Administrator. Resident medications and medication administration records were reviewed and found to be in compliance at this time.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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: VENEMAN CARE HOME	FACILITY NUMBER: 502700990
	VISIT DATE: 02/24/2023

NARRATIVE

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The staff lounge was also reviewed by the LPAs. It was learned that this facility employed live-in caregivers at this time.

The following forms and documents were requested to be updated and submitted into CCL for review by this LPA:

LIC 308

LIC 400

LIC 500

LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

A civil penalty in the amount of $500 was issued at the time of this annual visit on the following LIC 421IM (7/17).

The appeal rights were printed and a copy was left with the facility designated Administrator at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/28/2023 01:09 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: VENEMAN CARE HOME	FACILITY NUMBER: 502700990
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87204(a)

Limitations -Capacity and Ambulatory Status

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews with the designated facility administrator, Lolita Ramit, this facility was accommodating two bedridden residents at the time of this annual review. It was learned that this facility does not possess an valid bedridden fire clearance at this time. This posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/24/2023
	Plan of Correction
1 2 3 4	The designated facility Administrator and/or Licensee will apply for the proper bedridden fire clearance through Community Care Licensing and submit the required forms and documents by the due date of 02/24/2023.

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, this LPA witnessed toxic chemicals in an unlocked cabinet in the laundry room as well as two bottles of toilet cleaner in one of the restrooms. These chemicals posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/25/2023
	Plan of Correction
1 2 3 4	Licensee stated that this facility will secure all of toxic chemicals in a locked cabinet to make them inaccessible to the residents at all times. A statement of correction, along with a photo of the cleared areas and locked cabinet will be completed and submitted into this LPA by the due date of 02/25/2023.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/28/2023 01:09 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: VENEMAN CARE HOME	FACILITY NUMBER: 502700990
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. 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, this LPA witnessed scissors in an unlocked drawer in the kitchen as well as in an unlocked drawer in the hallway bathroom These scissors posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/25/2023
	Plan of Correction
1 2 3 4	Licensee stated that this facility will secure all of the scissors in a locked cabinet to make them inaccessible to the residents at all times. A statement of correction, along with a photo of the cleared areas and locked drawer will be completed and submitted into this LPA by the due date of 02/25/2023.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/28/2023 01:09 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: VENEMAN CARE HOME	FACILITY NUMBER: 502700990
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation by this LPA, the slider screen off the master bedroom adjacent to the backyard had a hole, tear, or rip and posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2023
	Plan of Correction
1 2 3 4	Licensee stated that this facility will repair or replace the slider screen so that it will no longer have any holes, tears, or rips in them. A statement of correction, along with a photo of the repaired/replaced screen will be completed and submitted into this LPA by the due date of 02/27/2023.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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