507002396-9-29-2023-27-AS-CYAG-CW5MBS-20230929092825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507002396
Report Date: 09/28/2023
Date Signed: 09/29/2023 09:36:48 AM

Document Has Been Signed on 09/29/2023 09:36 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:	SAMARITAN VILLAGE		FACILITY NUMBER:	507002396
ADMINISTRATOR:	RIKKI PEREZCHICA		FACILITY TYPE:	740
ADDRESS:	7700 FOX ROAD		TELEPHONE:	(209) 883-3000
CITY:	HUGHSON	STATE: CA	ZIP CODE:	95326
CAPACITY:	277	CENSUS: 180	DATE:	09/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Kaylie McCortney		TIME COMPLETED:	02:00 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	Unannounced annual visit made out to this facility on 09/28/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility Care Operations Manager Kaylie McCortney since the facility designated Administrator, Rikki Perezchica, was unavailable at this time. A brief interview was conducted with the facility representative, Kaylie McCortney, at this time. It was learned that there were residents under the care of hospice(9) at this time while other residents were receiving services through home health (15) as well. This facility does have a hospice waiver approved for (15) residents and fire cleared for bedridden (2) and dementia care for residents at any given time. Current census was 180 residents. A tour of this facility was conducted alongside the facility Care Operations Manager. Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator. Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication room, located on the first floor, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the facility designated medication technicians at this time. The medication carts were observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restroom was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. It was learned that there were (7) different floor plans for residents on the Assisted Living portion of this facility.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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: SAMARITAN VILLAGE	FACILITY NUMBER: 507002396
	VISIT DATE: 09/28/2023

NARRATIVE

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Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Linen closet, located in the facility laundry area, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
This facility does not have a dedicated Memory Care unit at this time. Dementia diagnosed residents are integrated into the main census of Country Manor.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 03/02/2023 by the local fire extinguisher company, Cisco Fire and Sprinkler, and in compliance at this time.
First aid kits were observed to be present and contained all of the required components at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted.

A review of (5) facility resident files was conducted.
A review of (5) facility personnel files was conducted.

The following forms and documents 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

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/29/2023 09:36 AM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SAMARITAN VILLAGE	FACILITY NUMBER: 507002396
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87415(a)

Night Supervision

(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [4] out of [5] facility personnel records did not contain updated first aid training as required which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	The facility designated representative stated that all facility personnel providing care and supervision to the residents in care shall be trained in First Aid. Proof of said training will be documented and certified on file at all times as well. A statement of correction will be completed, along with documented proof of updated First Aid training, to be submitted into CCL by the due date.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/29/2023 09:36 AM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SAMARITAN VILLAGE	FACILITY NUMBER: 507002396
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [4] out of [5] facility personnel records did not contain updated annual training hours as required which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/05/2023
	Plan of Correction
1 2 3 4	The facility designated representative stated that all facility personnel providing care and supervision to the residents in care shall be trained, initially and annually, to receive the required number of hours with the required topics. Proof of said training will be documented and certified on file at all times as well. A statement of correction will be completed, along with documented proof, to be submitted into CCL by the due date.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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