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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001184
Report Date: 11/20/2021
Date Signed: 11/20/2021 03:49:45 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/20/2021 03:49 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:DAVIS GUEST HOME #5FACILITY NUMBER:
507001184
ADMINISTRATOR:HEATHER MCCLOSKYFACILITY TYPE:
740
ADDRESS:2405 MAUNA LOA DRIVETELEPHONE:
(209) 556-9204
CITY:CERESSTATE: CAZIP CODE:
95307
CAPACITY: 8CENSUS: 7DATE:
11/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Taylor, Brittany, MelissaTIME COMPLETED:
03:43 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Staff 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 131 degrees Fahrenheit in client's bathroom sink, 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 expired medications without a back ordered replacement for R1 (photo taken). Also observed during the medication review was a bubble pack for R2 with medication pushed and re-taped, this is a medication error (Photo taken). Controlled medication count was not accurate for R3's Tramadol.

LPA reviewed 4 resident and 2 staff files, including criminal record clearances. First aid kit was checked and is complete. Fire drill was conducted on 11/03/2021.

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: 11/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2021
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 2
Document Has Been Signed on 11/20/2021 03:49 PM - It Cannot Be Edited


Created By: Albert Johnson On 11/20/2021 at 03:04 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 #5
FACILITY NUMBER: 507001184

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2021
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 the hot water at 131 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 A
11/21/2021
Section Cited
CCR80075(l)(1)A-D

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(l) Prescription medications which are not taken with the client upon termination of services, or which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client. (1) Both shall sign a record, to be retained for at least one year, which lists the following:
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Licensee shall dispose of expired medications and maintain medications as per regulation cited. An inservice for all medication passers shall be conducted as a refresher to be completed by 11/30/2021

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LPA and Med-tech observed expired medications without a back ordered replacement for R1. This poses a health and safety risk to resident.
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The facility will maintain for each client, records of centrally stored prescription medications destruction which shall be retained for at least one year.
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: 11/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2021


LIC809 (FAS) - (06/04)
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