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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004556
Report Date: 06/04/2021
Date Signed: 06/04/2021 08:20:01 PM

Document Has Been Signed on 06/04/2021 08:20 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:CASA DE LUZFACILITY NUMBER:
507004556
ADMINISTRATOR:MARIA L. ANDRADEFACILITY TYPE:
740
ADDRESS:3509 SCENIC DRTELEPHONE:
2095783077
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 5DATE:
06/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Andrade, AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arlene Garcia and (LPA) Albert Johnson conducted an unannounced annual / Infection Control visit on this date. LPAs were met by Tammy Hughes, Caregiver. LPAs met with Administrator, Maria Andrade.

LPA Arlene Garcia has completed a full file review. Mitigation Plan has been submitted and approved.

LPAs and administrator inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, medications rooms and dining room areas. LPAs observed sufficient seven days non-perishable and two days perishable food supplies in the main kitchen. Hot water temperature was measured in 1 residents bathroom with the Administrator, resident bathroom measured at 115.3 degrees which is in the required range of 105 to 120 degrees. Facility temperature measure 78 degrees.

LPAs and Administrator observed centrally stored medications. LPAs reviewed and compared resident medication vs. resident medication logs. LPAs found no documentation for PRNS for all residents, 2 medications found were expired, and 1 medication found was not in original packaging.

809-C Continued>>>>>>>>>>>>>>>>>>
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2021
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 06/04/2021 08:20 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 06/04/2021 at 11:05 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: CASA DE LUZ
FACILITY NUMBER: 507004556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2021
Section Cited

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Disaster and Mass Casualty Plan - Disaster drills shall be conducted at least every six months. The drills shall be documented and the documentation maintained in the facility for at least one year.
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This requirement is not met as evidenced by:
Based on records reviewed, care home states it is conducting fire drills but had not done one since COVID, a log is not present in the facility. This poses a potential safety risk to the residents in care.
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Administrator will email a copy of the fire drill log along with a statement of understanding of this regulation to LPA by POC due date of 06/14/2021.
Type B
06/04/2021
Section Cited

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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(e) Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash.

(1) The above requirement shall not prohibit the licensee from providing advances or loans to clients from facility funds.

(A) Documentation of such transactions shall be maintained in the facility.
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Based on records reviewed, LPAs observed Administrator comingling resident funds with facility funds and resident P&I. LPA discovered that staff depostied and cashed P&I check through facility business account, placed funds in resident P&I account.
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2021


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: CASA DE LUZ
FACILITY NUMBER: 507004556
VISIT DATE: 06/04/2021
NARRATIVE
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809 Cont. >>>>>>>>>>>>>>>>>>>>>>>>

Fire Drill has not been conducted since beginning of COVID, 2020. Administrator stated they have not kept a Fire Drill log in past. LPAs observed addition to the facility that was not on the original facility sketch submitted at application process.

LPAs completed an audit of P&I. LPAs observed the residents funds were accurate , however, the resident funds were commingled with facility funds.

LPAs reviewed 5 resident files and 3 staff files.

LPAs requesting updated Facility Sketch and Fire Clearance to be submitted to office.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with administrator and a copy of report given at the conclusion of the visit via email.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/04/2021 08:20 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 06/04/2021 at 01:25 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: CASA DE LUZ
FACILITY NUMBER: 507004556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/04/2021
Section Cited

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80075 Health Related Services (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met:
(A) There is a written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section 80075(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication re-evaluation.
(B) Once ordered by the physician the medication is given according to the physician's directions.
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Based on observation and records reviewed, licensee did not have PRNs letter for any residnets, medications were expired, and medications were not in original box. This poses an immedaite health and safety risk to residnets 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:Stephenie Doub
LICENSING EVALUATOR NAME:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2021


LIC809 (FAS) - (06/04)
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