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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001131
Report Date: 10/24/2021
Date Signed: 10/25/2021 06:52:41 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/25/2021 06:52 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DAVIS GUEST HOME IVFACILITY NUMBER:
507001131
ADMINISTRATOR:JESSICA SANCHEZFACILITY TYPE:
735
ADDRESS:1552 OHIO AVENUETELEPHONE:
(209) 549-0772
CITY:MODESTOSTATE: CAZIP CODE:
95358
CAPACITY: 34CENSUS: 30DATE:
10/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:13 PM
MET WITH:Gisell Gomez Med -TechTIME COMPLETED:
03:44 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Gisell Gomez and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 140 degrees Fahrenheit in client's hallway sink that is used for washing hands and brushing teeth, which is not the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. During the medication review LPA and Med-tech observed medications without a label (photo taken). Also observed during the medication review was a bubble pack for R1 with medication pushed for 10/25/2021, this is a medication error (Photo taken).

LPA reviewed 5 resident and 3 staff files, including criminal record clearances. First aid kit was checked and is complete. Fire drill was conducted on 8/21/2021.

Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted .
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2021
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 10/25/2021 06:52 AM - It Cannot Be Edited


Created By: Albert Johnson On 10/24/2021 at 03:05 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: DAVIS GUEST HOME IV
FACILITY NUMBER: 507001131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2021
Section Cited
CCR
80088(e)(1)

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Fixtures, Furniture Equipment and Supplies. Faucets used by clients shall deliver hot water, and attain temperatures of not less than 105 degrees F and not more than 120 degrees F.
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The facility will test the hot water for 3 days. Test hot water in the hallway resident wash area for three days to meet Title 22 regulations. Send 3 days of hot water temperatures to LPA via email.
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LPA tested hot water at 140 degrees F. Licensee failed to assure hot water meeting Title 22 regulation of 105-120 degree F. This poses a health and safety risk to resident in care.
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Type B
11/05/2021
Section Cited
CCR80075(D)

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(D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

(1) The specific symptoms which indicate the need for the use of the medication.

(2) The exact dosage.

(3) The minimum number of hours between doses.

(4) The maximum number of doses allowed in each 24-hour period.
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Licensee/administrator shall conduct an in-service for all staff employed including self on Title 22 medication administration policies/procedures,
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This requirement is not met as evidenced by: observation medications without a label (photo taken).
This is a potential health and safety risk
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including proper documentation/destruction procedures etc... Proof of training to be submitted to CCL by POC 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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2021


LIC809 (FAS) - (06/04)
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