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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002708
Report Date: 06/29/2022
Date Signed: 06/29/2022 02:46:08 PM

Document Has Been Signed on 06/29/2022 02:46 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:ST. CHARLES MANORFACILITY NUMBER:
507002708
ADMINISTRATOR:WOODRUFF, DORISFACILITY TYPE:
735
ADDRESS:3316 ST. ANN WAYTELEPHONE:
(209) 483-8725
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 4DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Madeline AmorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez and Arielle Pascua made an unannounced visit to this facility to conduct an annual inspection on 06/29/2022 at 10:00 AM. LPAs met with Madeline Amor and stated the purpose of today’s 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 of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate and expires on 11/16/2022. The facility is licensed for six non-ambulatory. There are currently 4 residents who reside at this facility.

LPAs toured the facility with Madeline Amor on 06/29/2021 at 10:30 AM.

The facility has a main entrance screening point, however, the facility does not have Covid-19 Precautionary visitor sign in log/book. The facility has Covid-19 posting throughout the facility. The facility has a 30 day supply of PPE. The facility conducts disinfecting cleaning daily.

The facility has an adequate supply of food. The facility has an adequate supply of plates and utensils. The facility water temprature measured at 110 degrees. The facility temperature was 77 degrees. During the visit, LPA Martinez smelled gas, and informed care staff Madeline Amor. Stove knob was not turned off. Madeline Amor was advised to open door for ventilation. LPA Martinez requested fire drill documentation. LPA Martinez and LPA Pascua inspected exit emergency exit gate, and it was locked and could not be open. Second exterior gate is not in good repair and has overgrown grass covering part of the door. Carbon and Smoke detectors are in good repair. Fire extinguisher is in good repair. First aid kit was complete. The facility medications and toxins are inaccessible to clients and secured in a lock cabinet.

Continued...

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
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 06/29/2022 02:46 PM - It Cannot Be Edited


Created By: Avelina Martinez On 06/29/2022 at 11:53 AM
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: ST. CHARLES MANOR
FACILITY NUMBER: 507002708

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2022
Section Cited

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Health Related Services 80075(5)(C):If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication...A record of each dose is maintained in the client's record...
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This requirement was not met as evidence by: Based on observation and file review, the Licensee did not ensure R1 MAR was completed to reflect medication was administered. This posed a potential health and safety to R1.
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Type B
07/14/2022
Section Cited

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Health Related Services 80075(D)(1)(2)(3)(4)
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....
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The specific symptoms which indicate the need for the use of the medication. The exact dosage. The minimum number of hours between doses...This requirement was not met as evidence by: Based on observation and file review, the Licensee did not ensure R1's OTC cough medicine have a Dr. Order. This posed a potential health and safety risk to R1.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/29/2022 02:46 PM - It Cannot Be Edited


Created By: Avelina Martinez On 06/29/2022 at 01:05 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: ST. CHARLES MANOR
FACILITY NUMBER: 507002708

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2022
Section Cited

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80020(a) Fire Clearance All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.
This requirement was not met as evidence by:
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Based on observation and file review, the licensee did not ensure exterior emergency/fire exit door was unlocked and in good repair. This posed an immediate health and safety risk to residents in care.
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Type A
06/29/2022
Section Cited

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Health and Safety Code 1569.50(a)(3)
Conduct Inimical: Conduct which is inimical to health, morals, welfare or safety of either an individual in, or receiving services from the facility or the people of the State of California. This requirement was not met as evidenced by
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based on observation the facility did not implement COVID-19 pre-screening measures at entrance of facility. 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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022


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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ST. CHARLES MANOR
FACILITY NUMBER: 507002708
VISIT DATE: 06/29/2022
NARRATIVE
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LPA Martinez and LPA Pascua reviewed 4 out of 4 resident files. 3 out of 4 resident files were complete. 1 Resident file was not complete. Resident 1 (R1) files was missing Health Certification Form (LIC 602). A technical violation was given to the facility. LPA Martinez and LPA Pascua reviewed 2 out of 4 resident medication Administration Records (MAR). 1 out of 2 MAR was not complete. R1's over the counter cough (OTC) medication did not have a prescription order label, and the facility did not have a doctors order for the OTC cough medication. In additions, MAR was not completed, and its unknown if medication was administrated per doctors orders. LPA Martinez and LPA Pascua reviewed 3 out 6 employee files. The employee files were complete.
  • Facility staff was informed an immediate civil penalty of $500 was assessed for a violation of Section on 06/29/2022.

  • Facility staff was informed an immediate civil penalty of $500 was assessed for a violation of Section on 06/29/2022.

As a result of this visit, deficiencies were cited per California Code of Regulations, Title 22 and Health and Safety Code. Exit interview was conducted, and a copy of 809, 809D, and appeals rights were given to the facility at the end of visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC809 (FAS) - (06/04)
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