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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002396
Report Date: 02/01/2024
Date Signed: 02/01/2024 02:32:45 PM


Document Has Been Signed on 02/01/2024 02:32 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:SAMARITAN VILLAGEFACILITY NUMBER:
507002396
ADMINISTRATOR:RIKKI PEREZCHICAFACILITY TYPE:
740
ADDRESS:7700 FOX ROADTELEPHONE:
(209) 883-3000
CITY:HUGHSONSTATE: CAZIP CODE:
95326
CAPACITY:277CENSUS: 179DATE:
02/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Rikki PerezchicaTIME COMPLETED:
03:00 PM
NARRATIVE
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On 02/01/2024, Licensing Program Analyst Renee Campbell arrived at the above facility at approximately 9:30 am. LPA Campbell met with Kaylie McCortney and Administrator Rikki Perezchica and shared the purpose of the visit.

The purpose of this case management visit was to follow up on the Incident Report (IR) submitted by the facility on 12/18/23. Per the Incident Report, expired insulin (exp. 12/12/23) was discovered by a Med Tech during the medication pass procedure. The 602, IR and MAR for R1 were observed by LPA Campbell.

As a result of this visit, it was determined that the facility followed reporting regulations and the following deficiencies and plan of correction were observed (see LIC 809-D for deficiencies cited).



Exit interview with Staff Appeals rights printed.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
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 02/01/2024 02:32 PM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: SAMARITAN VILLAGE
FACILITY NUMBER: 507002396

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2024
Section Cited
CCR
87465(c)(2)

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Incidental Medical and Dental Care 87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by :
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The Medication Management Supervisor removed the responsible staff from the Med Tech position and now requires supplementary documentation for medication to be added to the electronic MAR. POC completed during visit as observed by LPA Renee Campbell
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Based on a record review, observation and interviews, staff did not verify the expiration date for the insulin before providing it to the resident. This poses an immediate health and safety risk to residents in care.
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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 RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2