502700990-2-1-2024-27-AS-MJEN-D22VVH-20240201154622

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700990
Report Date: 02/01/2024
Date Signed: 02/01/2024 03:46:35 PM

Document Has Been Signed on 02/01/2024 03:46 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:	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: 6	DATE:	02/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Leilani Ramiro		TIME COMPLETED:	04:00 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 2/1/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced visit to conduct a required 1 year annual inspection. LPA Jensen met with Licensee Leilani Ramiro and explained the purpose of today's visit. LPA Jensen toured the facility grounds. All paths were observed to be free of obstruction. The grounds were well maintained. There are shaded areas and patio furniture for outdoor activities. All screens were observed to be in good repair. There is a swimming pool on site that is surrounded by a fence that is regulation height. At the time of this inspection the fence surrounding the swimming pool was observed to be locked. LPA Jensen toured the physical plant and observed it to be sanitary and free of odor. All required postings were observed. There was adequate lighting and furnishings throughout. The facility maintains an adequate linen supply. The bathrooms are equipped with grab bars and non-slip mats in the showers. The bathroom water temperature was measured at 109 degrees Fahrenheit which falls within the required range of 105-120 degrees Fahrenheit. The thermostat was set 79 degrees which falls within the required range of 68-85 degrees Fahrenheit. LPA Jensen inspected the kitchen and observed a 2 day supply of perishable food and a 7 day supply of non-perishable food. Knives were observed to be locked and inaccessible to residents in care. All cleaning supplies and medications were locked and inaccessible to residents in care. The fire extinguisher was last serviced in January of 2024 and is in compliance. The carbon monoxide detector and smoke detector were observed to be in good working order. The facility conducts and logs regularly scheduled fire drills. There is emergency lighting and food available. The first aid kit was observed to be complete and in compliance. The Emergency Disaster Plan was reviewed and is current and in compliance. Continued on LIC 809C...

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

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: VENEMAN CARE HOME	FACILITY NUMBER: 502700990
	VISIT DATE: 02/01/2024

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
26
27
28
29
30
31
32

LPA Jensen interviewed 3 of 6 clients and all were satisfied with every aspect of their care. LPA Jensen reviewed 4 staff files and observed staff 4 (S4) to lack finger print clearance. A deficiency is being cited and a civil penalty assessed for lack of criminal background clearance. LPA Jensen reviewed 3 of 6 client files and observed 3 of 3 files to lack Needs and Service Plans and contain Physician Reports that were in excess of a year old. Technical assistance is being provided in multiple areas on documentation required for resident files.

LPA Jensen reviewed the Liability insurance and determined it to be current and in compliance. LPA Jensen reviewed the LIC 308 and it is in compliance.

The inspection tool was used during the course of this visit. Deficiencies are being cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6. Civil Penalties are also being assessed.

An exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 02/01/2024 03:46 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: VENEMAN CARE HOME	FACILITY NUMBER: 502700990
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.17(c)(1)(A)

Licensing

(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Jensen's review of staff files, the licensee did not comply with the section cited above in 1 out of 4 persons which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2024
	Plan of Correction
1 2 3 4	Licensee agrees to not allow the staff member to work until a valid criminal background clearance is obtained.

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: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5