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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701020
Report Date: 07/20/2023
Date Signed: 07/21/2023 10:37:21 AM

Document Has Been Signed on 07/21/2023 10:37 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:HOPE'S CARE HOMEFACILITY NUMBER:
502701020
ADMINISTRATOR:SOLORIO, GLORIAFACILITY TYPE:
735
ADDRESS:315 LALOMA AVETELEPHONE:
(209) 505-1236
CITY:MODESTOSTATE: CAZIP CODE:
95354
CAPACITY: 6CENSUS: 3DATE:
07/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Gloria SolorioTIME COMPLETED:
01:30 PM
NARRATIVE
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Unannounced annual licensing visit made out to this facility on 07/20/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by facility staff person, Vanessa Solorio, who was briefly interviewed. This LPA requsted that facility staff person go ahead and contact the facility designated Administrator, Gloria Solorio, to inform her that CCL was present at this time.
The facility designated Administrator, Gloria Solorio, arrived shortly thereafter while this LPA was conducting the annual visit. Brief interview was conducted with the facility designated Administrator at this time.
Current census was 3 residents.
Tour of this facility was conducted.
Kitchen area was toured. Cabinets and drawers were reviewed. Drawers and cabinets housing cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Food supply was reviewed for 2-day perishable and 7-day nonperishable food quantities at this time.
Dining room, living area, and all other areas designated for resident use were observed to be maintained and observed to be in compliance at this time.
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be present and maintained in compliance at this time.
A tour of the resident restrooms was conducted. Grab bars and non skid mats were observed to be present and in compliance at this time.
Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Medication for resident use, located in hallway cabinet, was reviewed. Policies and procedures for dispensing, handling, and overall documentation of the resident medications were discussed with the facility designated Administrator at this time.
Fire extinguisher was observed to be placed in the kitchen area and was annually purchased on 07/12/2023 from the local hardware company and in compliance at this time.
First aid kit was observed to be present and contained all of the required components at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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: HOPE'S CARE HOME
FACILITY NUMBER: 502701020
VISIT DATE: 07/20/2023
NARRATIVE
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Linen closet, located in facility hallway, was observed to contain a sufficient supply of blankets, sheets, and towels for resident use.
Laundry area, located in adjacent facility building, was observed to be made available to the residents at this time for those who were capable of doing so. Laundry detergents, bleach, and all other cleaning supplies were observed to be stored elsewhere where they were locked and made inaccessible to the residents at this time.
Exterior grounds of this facility was toured. Facility perimeter fence, side gates, and emergency exits were reviewed.
Additional garage space was reviewed and observed to be contain materials and items intended for upkeep and maintenance of this facility.

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

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 Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/21/2023 10:37 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/20/2023 at 03:14 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: HOPE'S CARE HOME
FACILITY NUMBER: 502701020

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
Based on record review, the licensee did not comply with the section cited above in [5] out of [5] personnel records were incomplete and did not contain all of the required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 07/27/2023
Plan of Correction
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The facility representative stated that all personnel files will be updated to contain all required forms and documents. A statement of correction, along with copies of the updated forms, will be completed and submitted into CCL by the due date.
Type B
Section Cited
CCR
80070(a)
The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [3] out of [3] resident files were incomplete missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2023
Plan of Correction
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The facility representative stated that all resident records will be updated to contain all required forms and documents. A statement of correction, along with copies of all updated forms, will be completed and submitted into CCL by the due date.
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
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023


LIC809 (FAS) - (06/04)
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