507003709-2-16-2024-27-AS-CYAG-D2HVDL-20240216152055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507003709
Report Date: 02/14/2024
Date Signed: 02/16/2024 03:21:28 PM

Document Has Been Signed on 02/16/2024 03:21 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:	CHANCELLOR MANOR		FACILITY NUMBER:	507003709
ADMINISTRATOR:	CLARITA RAMISCAL		FACILITY TYPE:	740
ADDRESS:	5707 CHANCELLOR WAY		TELEPHONE:	(209) 858-8830
CITY:	RIVERBANK	STATE: CA	ZIP CODE:	95367
CAPACITY:	6	CENSUS: 5	DATE:	02/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Nicetas Abella		TIME COMPLETED:	01:30 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 02/14/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated representative Nicetas "Nancy" Abella. A brief interview was conducted with the facility designated representative at this time. Current census was 5 residents. It was learned that there weren't any residents under the care of hospice at this time. This facility does have a hospice waiver to be able to accept and retain up to (2) hospice residents at any given time. It was learned that there weren't any residents receiving any care from a home health care agency at this time. It was learned that there weren't any residents diagnosed with dementia at this time. A tour of this facility was conducted. Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Clarita Ramiscal. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the certificate expiration date of 10/16/2024 with certificate #6018164740. Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet, located in a separate hallway cabinet, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated representative at this time. This medication cabinet was observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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 4

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: CHANCELLOR MANOR	FACILITY NUMBER: 507003709
	VISIT DATE: 02/14/2024

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
26
27
28
29
30
31
32

Linen closet, located in the hallway, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected by the local fire extinguisher company, Assured Fire Extinguisher Company, on 01/15/2024 and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.
A review of (5) facility resident records was conducted and noted on the following LIC 858 form.
A review of (2) facility staff records was conducted and noted on the following LIC 859 form.

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.

A civil penalty was assessed in the amount of $500 on the following LIC 421IM.

Appeal Rights were printed and a copy was given to the facility designated representative at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 02/16/2024 03:21 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: CHANCELLOR MANOR	FACILITY NUMBER: 507003709
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the hot water dispensed in the resident restroom was measured and observed to be at 128.4 degrees which was above the allowed range of 105-120 degrees which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/15/2024
	Plan of Correction
1 2 3 4	The facility representative stated that the hot water heater will be turned down and measured on a daily basis. A log will be maintained for (7) days to make sure that the hot water being dispensed is always within the allowed range of 105-120 degrees. A statement of correction, along with a copy of the hot water measurement log for (7) days, will be completed and submitted into CCL by the due date.

Type A

Section Cited

CCR

87606(c)

Care of Bedridden Residents

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). 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 that [1] out of [5] resident files was diagnosed as being "Bedridden" but this facility does not have an approved bedridden fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/15/2024
	Plan of Correction
1 2 3 4	The facility representative stated that the proper forms and documents will be submitted into CCL to request for a bedridden fire clearance. A statement of correction, along with all required forms and documents, will be completed and submitted into CCL by the due 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: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 02/16/2024 03:21 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: CHANCELLOR MANOR	FACILITY NUMBER: 507003709
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: 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 [5] out of [5] resident files were missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2024
	Plan of Correction
1 2 3 4	The facility representative stated that all resident files will be reviewed and any missing forms and documents will be updated. A statement of correction, along with copies of the updated forms and documents, will be completed and 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: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4