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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004929
Report Date: 10/31/2023
Date Signed: 10/31/2023 12:45:02 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/31/2023 12:45 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 IFACILITY NUMBER:
507004929
ADMINISTRATOR:CANDIDO, CECILIAFACILITY TYPE:
740
ADDRESS:4112 LAURANT COURTTELEPHONE:
(209) 521-0566
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 3DATE:
10/31/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Marilou OliverTIME COMPLETED:
12:00 PM
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LPA Jensen arrived at facility unannounced to continue an annual inspection that was commenced on 10/17/23. LPA Jensen met with care provider Marilou Oliver and explained the purpose of today's visit.

On 10/17/23 LPA Jensen toured the grounds and interior physical plant. LPA Jensen observed a swimming pool in the backyard that was locked and inaccessible to residents in care. There was outdoor seating available for client activities. LPA Jensen observed 4 torn window screens in the backyard. The outdoor grounds appeared to be maintained and outdoor paths were clear of obstruction.

LPA Jensen toured the facility kitchen. A 2 day supply of perishable food and a 7 day supply of non-perishable food was on hand. LPA Jensen did a random sampling of canned goods and observed 5 expired canned food products, rotting parsley in the refrigerator, salad that expired on 10/8/23, food in storage containers that was not labeled and several items with freezer burn.

LPA Jensen toured the resident bedrooms and observed all required furniture present. The facility uses waterproof mattress covers on the beds. The facility maintains an adequate supply of linens and hygiene products. LPA Jensen observed the Resident 1 (R1) to be in bed. The bed is adjacent to the wall on one side and blocked on the other side by a chair, walker and portable commode in such a manner that R1's ability to get out of bed would be restricted.

LPA Jensen attempted to conduct a random medication audit for Resident 2 (R2) but was unable as the facility does not maintain centrally stored medication and destruction records.

LPA Jensen reviewed 3 of 3 resident files. 3 of 3 resident admission agreements state that an increase in the monthly rate charged may be initiated after 30 days of notice. 1 of 3 resident admission agreements states that there are no refunds provided.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
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: 10/31/2023
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LPA Jensen reviewed the first aid kit and found it to be complete and in compliance. The carbon monoxide detector, smoke detector and fire extinguisher were determined to be in compliance. The facility maintains an adequate emergency supply of food and water. There is emergency lighting available. The facility conducts regular fire drills and is in compliance. The thermostat was set at 68 degrees which falls within the required range of 68-85 degrees Fahrenheit. The water temperature was measured in the bathroom in the main hall All required postings were observed to be easily viewable.

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, the LIC 811 and appeal rights were provided.



SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/31/2023 12:45 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: 10/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2023
Section Cited
CCR
87555(a)

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General Food Service Requirements
...All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by:
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The facility staff began conducting an inventory of the food supply and discarding expired food. The Licensee agrees to conduct a monthly audit of the food supply to identify and discard of all expired food.
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Based on LPA Jensen's observation of expired food in the pantry and refrigerator and food items requiring refrigeration being stored in the pantry. This poses a potential risk to the health, safety and personal rights of residents in care.
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Type B
12/08/2023
Section Cited
HSC1569.655(a)

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 If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives. This requirement was not met as evidenced by:
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The Licensee agrees to establish new admission agreements signed by the resident or responsible party if applicable that are in compliance with the HSC. The Licensee will send the admission agreement to LPA Jensen by the Plan of Correction due date.
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Based on LPA Jensen's review of 3 of 3 resident files that indicate rate increases may be made after 30 days. 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/31/2023 12:45 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: 10/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2023
Section Cited
CCR
87608(a)(3)

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Postural Supports
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement was not met as evidenced by:
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The facility staff called the Primary Care Physician requesting authorization for postural supports for R1 during the course of this visit and in the presence of the LPA. The facility staff will either remove the postural supports or send confirmation that the physician has given approval by 11/6/23.
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Based on LPA Jensen's observation of R1's bed being blocked by various items effectively restricting R1's mobility without a physician's order. This poses an immediate 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4