507004556-5-17-2023-27-AS-APAA-CRWQQU-20230517122254

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004556
Report Date: 05/17/2023
Date Signed: 05/17/2023 12:23:48 PM

Document Has Been Signed on 05/17/2023 12:23 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 LUZ		FACILITY NUMBER:	507004556
ADMINISTRATOR:	JOHANNA WEST		FACILITY TYPE:	740
ADDRESS:	3509 SCENIC DR		TELEPHONE:	(209) 578-3077
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	6	CENSUS: 6	DATE:	05/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Johanna West		TIME COMPLETED:	12:45 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	On 05/17/2023 at 10:00am, Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct an annual visit. LPA was greeted by staff member (SM), Marvin Chy, and explained the purpose of the visit. LPA asked SM Chy to go ahead and inform the Facility Designated Administrator (FDA) that licensing was present at the facility. Shortly after, LPA met Facility Designated Representative (FDR), Maria Andrade. It was learned at this time that FDA West was not available. There were two other staff members present during this visit, Taylor Andrade and Alethia Alvarez. This facility is licensed to serve up to 6 elderly residents. This facility does not currently have a dementia plan on file and does not have a hospice waiver. Current census was 6. A brief interview was conducted with FDR Andrade. LPA reviewed 6 resident files. 6 out of 6 resident files were current and up to date. LPA reviewed 6 staff files. 4 out of 6 staff files were complete. The Facility Designated Administrator has an active and current administrator certificate #6059262740 and expires on 08/10/2023. A tour was initiated with FDR Andrade. Fire extinguisher was serviced by Jorgenson Co and is valid until 06/01/2023. Smoke alarms and carbon monoxide were in good repair. A tour of the kitchen was conducted. LPA observed a sufficient amount of 7 day non-perishable food supply as well as 2 day perishable food supply in the main kitchen. Knives were observed to be locked and made inaccessible to the residents. Additional perishable food supply was identified in the garage. LPA observed a locked centralized stored medication cabinet. Along with FDR Andrade, LPA reviewed and compared medication with medication dispensing logs. LPA observed a locked cleaning supply cabinet. First aid kit was present and contained all the required components. Living room area, dining room, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be in good repair and sufficient to meet resident needs at this time. A tour of 3 resident bedrooms were conducted. Resident furniture was observed to be sufficient to meet their needs at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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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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: 05/17/2023

NARRATIVE

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A tour of the resident bathrooms were conducted. Hot water temperature was within the required range of 105-120 degrees. Grab bars were present.

Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.

A tour of the exterior physical plant was conducted. Perimeter fence, side gates, and exits was inspected.

The following forms and documents were requested to be updated and submitted into CCL:
-LIC 308

-LIC 400

-LIC 500

-LIC 610

-Liability insurance

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

Exit Interview was conducted, a copy of this report and appeals rights were provided to the Facility at the end of this visit.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/17/2023 12:23 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: CASA DE LUZ	FACILITY NUMBER: 507004556
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(c)(1)

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not obtaining First Aid certification for 2 staff members. 2 out 6 staff members first aid was observed to be expired and out of compliance. This poses a immediate health, safety and personal rights risks to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	Licensee agrees to provide a written statement to LPA that states that they have read the regulation to it's entirety by POC date 05/18/2023. In addition, Licensee agrees to provide a copy of First Aid training and certificates to the LPA's email. arielle.pascua@dss.ca.gov

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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

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