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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004929
Report Date: 01/25/2024
Date Signed: 01/25/2024 01:56:10 PM


Document Has Been Signed on 01/25/2024 01:56 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: 2DATE:
01/25/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cecelia CandidoTIME COMPLETED:
02:15 PM
NARRATIVE
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On 1/25/24 Licensing Program Analyst (LPA) Maja Jensen and Stanislaus County Ombudsman Josey Samson arrived at facility unannounced to conduct a quarterly visit. LPA Jensen met with Licensee Cecelia Candido and Co-Administrator Nikolas Adamsson and explained the purpose of today's visit.

The Licensee was informed that at any time if she wishes to use an interpreter the Department will provide an interpreter upon request. The facility currently has a census of 2. LPA Jensen requested the file for Resident 2 (R2). LPA Jensen observed an Admission agreement dated 4/13/2018 stating that the resident has a double room. LPA Jensen also observed 2 receipts billing for a private room. One receipt for April through June and one receipt for April through May of 2018. LPA Jensen asked the Licensee why there are receipts in the file billing for a private room and an admission agreement stating there R2 will occupy a double room. The Licensee stated the receipts in question were never sent and were placed in the file in error. The Licensee confirmed that the resident has always occupied a double occupancy room. LPA Jensen requested the correct receipts and was advised no other receipts were ever sent or generated. LPA Jensen observed the Needs and Service Plan for R2 to be dated April 2, 2018. The Licensee produced an additional Needs and Service Plan dated 3/23/2019 with no signatures.

LPA Jensen reviewed the Medication Administration Record (MAR) for R2, the MAR reflects that on January 11 through and including January 15, 2024, R2 did not receive a prescribed dopamine promoter. LPA Jensen was advised that the prescription medication ran out on January 10, 2024 and the facility placed 3 calls to the pharmacy for a refill but these calls were not documented. LPA Jensen reviewed the Centrally Stored Medication and Destruction Record which shows that the prescription was refilled 12/21/23 and was started on 1/7/24. There was no explanation as to why these records were in conflict.

LPA Jensen tested the water in the bathroom toward the rear of the facility and the temperature was measured at 103 degrees. Technical assistance was provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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 4


Document Has Been Signed on 01/25/2024 01:56 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: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/25/2024
Section Cited
HSC
1569.884

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Contents of Residential Care Facility Admission Agreements
The admission agreement shall include all of the following:
(a) A comprehensive description of any items and services provided under a single fee, , such as a monthly fee for room, board...
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The Licensee agrees to send monthly receipts to the payee effective immediately and retain those receipts in the file.
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 the resident shall receive a monthly statement itemizing all separate charges incurred by the resident. This requirement was not met as evidenced by Licensee's admission that file receipts were inaccurate and no other receipts were generated. This poses a potential risk to the health, safety and personal rights of 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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 01/25/2024 01:56 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: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2024
Section Cited
CCR
87464(f)(4)

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Basic Services
Basic services shall at a minimum include:
...assistance with taking prescribed medications...This requirement was not met as evidenced by:
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The Licensee agrees to document all communications with resident physicians and the pharmacy effective immediately and reconcile the MAR with the Centrally Stored Medication and Destruction Record.
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Based on LPA Jensen's review of the MAR, R2 did not receive a prescribed medication from 1/11/24 through 1/15/24. This poses an immediate risk to the health, safety and personal rights of residents in care.
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Type B
02/22/2024
Section Cited
CCR87467(a)(3)

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Resident Participation in Decision Making
The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident’s condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.
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The Licensee agrees to submit updated Needs and Service Plans that fully comply with this regulation by the POC due date.
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This requirement was not met as evidenced by LPA Jensen's review of R2's file which contained a Needs and Service Plan conducted in 2018. 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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4