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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507003709
Report Date: 02/10/2023
Date Signed: 02/10/2023 05:36:51 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/10/2023 05:36 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:CHANCELLOR MANORFACILITY NUMBER:
507003709
ADMINISTRATOR:CLARITA RAMISCALFACILITY TYPE:
740
ADDRESS:5707 CHANCELLOR WAYTELEPHONE:
(209) 858-8830
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY:6CENSUS: 2DATE:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Terisita NewaluTIME COMPLETED:
05:30 PM
NARRATIVE
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On 2/10/2023 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual inspection. LPA Jensen met care provider Terisita Newalu. LPA Jensen spoke to Licensee Clarita Ramiscal by telephone and explained the purpose of today's visit.

The facility has 4 resident bedrooms and 1 live in staff room. The care provider present at the facility was confirmed to be finger print cleared and associated to the facility. The facility was observed to have adequate lighting, furniture and was sanitary. The first aid kits were observed to be complete with scissors, tweezers, thermometer and first aid manual. The fire extinguisher was last serviced in January of 2023 and is in compliance. The carbon monoxide and smoke detector was tested and determined to be in good working order. There is an emergency food supply and 30 days of PPE on hand. Signs were observed to be posted throughout the facility for COVID mitigation, Ombudsman, resident council, resident rights and "See something, Say Something".

The facility was observed to have in excess of 2 days of perishable food and 7 days of non-perishable food. Knives, toxins and medications were observed to be locked and inaccessible to residents in care. The bathrooms were observed to have grab bars at the toilet and in the shower. The temperature was set to 72 degrees and is within the required regulatory range of 68-85 degrees for the comfort of the residents. The grounds were observed to be maintained and all paths were clear of obstruction.

LPA Jensen reviewed 2 of 2 resident files. 2 of 2 resident files did not have an updated LIC 602 or LIC 625 despite LPA Jensen's observation that a change in the residents condition had occurred.

Continued on LIC 809C...

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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 3


Document Has Been Signed on 02/10/2023 05:36 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: CHANCELLOR MANOR
FACILITY NUMBER: 507003709

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2023
Section Cited

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The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement was not as evidenced by:
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The Licensee agrees to obtain a new physician report and complete a new appraisal needs and service plan and sendby email to maja.jensen@dss.ca.gov by POC due date.
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Based on LPA Jensen review of 2 of 2 resident files teh residents condition had changed since the last apprasial was done but teh change was not documented. This poses a potential risk to the health, safety and personal rights of 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: CHANCELLOR MANOR
FACILITY NUMBER: 507003709
VISIT DATE: 02/10/2023
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Resident 1 (R1) was admitted to the facility capable of using a walker and capable of self feeding however this is no longer appears to be the case. Resident 2 (R2) also entered the facility using a walker and able to self feed and this is no longer the case. R2 is no on hospice.

LPA Jensen requested a copy of the current LIC 500 and the current liability insurance to be emailed to maja.jensen@dss.ca.gov by 2/17/23.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC809 (FAS) - (06/04)
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