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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004929
Report Date: 10/08/2021
Date Signed: 10/08/2021 12:47:06 PM

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:DUTCHOLLOW SUITES IFACILITY NUMBER:
507004929
ADMINISTRATOR:CANDIDO, CECILIAFACILITY TYPE:
740
ADDRESS:4112 LAURANT COURTTELEPHONE:
(209) 521-0566
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 2DATE:
10/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Cecilia CandidoTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Sarah Hurt conducted an unannounced visit today for the facilities annual inspection. LPA met with Administrator Cecilia Candido Continual Administrator's Certification expires 06/27/2022. There are currently 2 residents who reside at this facility. LPA'S inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. LPA observed a swimming pool that is locked and inaccessible to all residents. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 110 F degrees. First Aid kit is on site and complete.

Per California Code of Regulations, Title 22 Division 6, Chapter 8 and Health and Safety Code, deficiencies were cited on the 809D, in addition to advisory notes


LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Administrator and copy of report left at facility
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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
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: DUTCHOLLOW SUITES I
FACILITY NUMBER: 507004929
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87887(h)(1)
BUILDINGS AND GROUNDS (h)Disinfectants, cleaning solutions, poisons, firearms, and other items which could pose a danger if readily available to residents shall be stored where inaccesible to residents.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above. LPA observed disinfectants on the back patio unlocked and accesible to residents. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2021
Plan of Correction
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Licensee removed cleaning solutions from back patio. Licensee will clean back patio and send photos to LPA.
Type A
Section Cited
CCR
87303(A)



Maintenance and Operations (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed clutter all over the entire home. The entire home was filled with belongings from a storage unit outside. The kitchen area was not usable as it had items scattered all over the counters which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2021
Plan of Correction
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Licensee will clean entire kitchen and living room area and sent photo proof to LPA by POC 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2021
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: DUTCHOLLOW SUITES I
FACILITY NUMBER: 507004929
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(h) the following requirements shall apply to medications which are centrally stored. (2) centrally stored medicines shall be kept in a safe and lcoked place that is not accesible to persons other than employees responsible for the supervision of the cetnrally stored medications.




This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed several over the counter medications out on the kitchen table upon the entering the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2021
Plan of Correction
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Facility staff will be trained on the medication regulation along with licensee. Licensee will send proof of training to LPA. Licensee will review the regulation section and provide a statement of understanding.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3