507004929-10-17-2023-27-AS-MJEN-CWPVSF-20231017164128

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004929
Report Date: 10/17/2023
Date Signed: 10/17/2023 04:41:53 PM

Document Has Been Signed on 10/17/2023 04:41 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:	DUTCHOLLOW SUITES I		FACILITY NUMBER:	507004929
ADMINISTRATOR:	CANDIDO, CECILIA		FACILITY TYPE:	740
ADDRESS:	4112 LAURANT COURT		TELEPHONE:	(209) 521-0566
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	6	CENSUS: 3	DATE:	10/17/2023
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Cecelia Candido		TIME COMPLETED:	12:00 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 10/17/23 at approximately 10:15 am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly visit and follow up on the progress and maintenance of previously discussed directives. LPA Jensen met with Nick Adamsson and explained the purpose of today's visit. On 10/12/22 an informal conference was held to discuss deficiencies in the areas of: Food service · Medications accessible to residents · Chemicals accessible to residents · Facility is not clean and in good repair · Swimming pool (empty) accessible to residents · Knives accessible to residents · Resident Personal Rights The facility agreed to do the following: - Lock all medications in a cabinet making them inaccessible to residents · Lock the pool making it inaccessible to residents · Keep chemicals in garage locked away · Combustible chemicals to be kept locked away near empty pool · Provide updated floor plan to include one storage room (store clutter) · Ensure the facility, and all resident bedrooms are clean and not full of clutter. The License agreed to engage in the Technical Support Program offered by the Department and a corresponding meeting on 5/11/23 during which the Licensee agreed to: - conduct Personal Rights Training every 6 months and upon new hire. -clean and organize the client/storage room prior to the next quarterly visit

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DUTCHOLLOW SUITES I	FACILITY NUMBER: 507004929
	VISIT DATE: 10/17/2023

NARRATIVE

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During the course of the visit LPA Jensen observed the following:

-scissors accessible to residents in the night stand of the bedroom for resident 1(R2)
-a nail gun, protractable knife and latex caulk in an unlocked closet
-medication on the kitchen table not locked and accessible to residents
-a gallon of bleach on the kitchen floor
-numerous boxes of night time cold and flu medicine in a drawer under the TV stand for which there was no PRN
-health related oral supplements for which there was no PRN
-a case of Ensure in the bedroom of resident 2 (R2)
-A hoyer lift blocking a fire exit in the bedroom of R1
-A clothes dresser and chair blocking a sliding glass door exit in the bedroom for R2
-A sign on a client bedroom that read STAFF which was removed when LPA Jensen brought this matter to the Licensee's attention
-dead flies in the living room, hallway and bedroom of R2

LPA Jensen observed documentation showing personal rights training was conducted in June of 2023 and is therefore in compliance. LPA Jensen observed the outdoor pool to be locked and inaccessible to residents and therefore in compliance.

Deficiencies are being cited from the California Code of Regulations (CCR) and/or the Health and Safety Code (HSC) Failure to correct deficiencies may result in the assessment of civil penalties and administrative action.

An exit interview was conducted and a copy of this report, the LIC 811 and appeal rights were provided.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/17/2023 04:41 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: DUTCHOLLOW SUITES I	FACILITY NUMBER: 507004929
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/18/2023 Section Cited CCR 87307(d)(6)	1 2 3 4 5 6 7	Personal Accommodations and Services All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee removed the obstructions during the course of the visit. No further plan of correction is required.
	8 9 10 11 12 13 14	Based on LPA Jensen's observation of a bedroom sliding door and bedroom door blocked by equipment or furniture. This poses a potential threat to the health, safety and personal rights of residents in care.	8 9 10 11 12 13 14
Type B 10/24/2023 Section Cited CCR87208(a)(7)(A)	1 2 3 4 5 6 7	Plan of Operation Each facility shall have and maintain a current, written definitive plan of operation...The plan and related materials shall contain the following: Sketches...including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents.	1 2 3 4 5 6 7	The Licensee will submit a sketch that accurately depict the usage of each room or sign an attestation that the current sketch is accurate.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by LPA Jensen's observation that a client room had been converted in to a staff room. This poses a potential threat to the health, safety and personal rights of residents in care.	8 9 10 11 12 13 14

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: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/17/2023 04:41 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: DUTCHOLLOW SUITES I	FACILITY NUMBER: 507004929
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/18/2023 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	Buildings and Grounds The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee removed all hazardous items and made them inaccessible during the course of the visit. No further plan of correction required.
	8 9 10 11 12 13 14	Based on LPA Jensen's observation of toxins, tools, sharp objects and insects. This poses an immediate risk to the health, safety and personal rights of residents in care.	8 9 10 11 12 13 14
Type A 10/18/2023 Section Cited CCR87465(h)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee agrees to conduct a daily walk through to ensure all medications are inaccessible to residents in care. The Licensee will email an attestation that daily walk throughs will be conducted.
	8 9 10 11 12 13 14	Based on LPA Jensen's observation upon arrival of medication in the kicthen that was accessible to residents in care. This poses an immediate risk to the health, safety and personal rights of residdents in care.	8 9 10 11 12 13 14

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: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC809 (FAS) - (06/04)

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