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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701290
Report Date: 06/18/2024
Date Signed: 06/19/2024 04:07:45 PM

Document Has Been Signed on 06/19/2024 04:07 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:CARVER CARE RESIDENTIALFACILITY NUMBER:
502701290
ADMINISTRATOR/
DIRECTOR:
CALLA, PATRICIAFACILITY TYPE:
735
ADDRESS:1009 CARVER ROADTELEPHONE:
(209) 204-5157
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 70CENSUS: 40DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator Ashley GudinoTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required inspection. LPA Lund met with the Administrator Ashley Gudino and explained the reason for the visit. Census: 40

LPA Lund and Administrator Ashley toured/inspected the facility inside and outside. The facility has 2 common areas, five staff offices, cleaning storage, resident phone area, linen storage, conference room, medical office, dining area, kitchen, break room, three staff bathrooms, nine clients’ showers, and eleven bathrooms. There are cameras in the inside common’s areas and on the outside of the building. The kitchen has 7-day
non-perishable and 2- day perishable foods and the staff are only allowed in the kitchen area.

The facility has locked medication room observed medications to be stored and secured. Fire extinguishers were done on October 5, 2023, and smoke detectors are in compliance with fire safety. First aid kit was checked and is complete. LPA Lund reviewed three staff & four clients files. During the review of the three staff files all three staff are missing their TB test health screening results.
There are cameras in the inside common’s areas and on the outside of the building.

Per California Code of Regulations, Title 22, the following deficiencies were cited. Exit interview conducted and report provided. Appeals rights printed.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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 06/19/2024 04:07 PM - It Cannot Be Edited


Created By: Jason Lund On 06/18/2024 at 01:32 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARVER CARE RESIDENTIAL

FACILITY NUMBER: 502701290

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

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 files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Administrator will get TB Test done for staff.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Rios
LICENSING EVALUATOR NAME:Jason Lund
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
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