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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004929
Report Date: 10/11/2022
Date Signed: 10/12/2022 09:54:48 AM

Document Has Been Signed on 10/12/2022 09:54 AM - 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: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:
10/11/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee, Cecilia CandidoTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit to the facility October 11, 2022 at 11:00 a.m for a POC visit. LPA met with Licensee Cecilia Candido and explained the purpose of the visit.


LPA Hurt toured the inside of the facility including kitchen, living areas, bathrooms, resident bedrooms, and outside areas. LPA observed the facility bedrooms to be extremely cluttered, and unlivable. LPA observed medications unlocked and accessible to residents in the living room, and kitchen areas of the facility. LPA observed the empty in ground swimming pool to be unlocked an accessible to residents. LPA walked into the area with the swimming pool and observed more garbage, and clutter along with more chemicals accessible to residents. LPA observed chemicals and cleaning solutions unlocked and accessible to residents under the facility kitchen sink, and garage area. LPA observed a large industrial size meat cutter in the garage area unlocked and accessible to residents.

The following deficiencies are being cited today Per Title 22 Regulations.

Exit interview conducted with Licensee, Cecilia Candido and a copy of this report provided .
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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
Document Has Been Signed on 10/12/2022 09:54 AM - It Cannot Be Edited


Created By: Sarah Hurt On 10/11/2022 at 12:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DUTCHOLLOW SUITES I
FACILITY NUMBER: 507004929

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2022
Section Cited
CCR
87307(e)

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Personal Accommodations(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water, when not in active use by residents, through fencing, covering or other means.The following requirement has not been met as evidenced by:
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Licensee will ensure the gate to empty swimming pool is locked and send proof to LPA by POC date of 10/12/2022.
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LPA Hurt observed a large empty in ground swimming pool in facility backyard to be unlocked and accessible to facility residents which poses an immediate, health safety or personal rights risk to residents in care.
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Type A
10/12/2022
Section Cited
CCR87465(h)(2)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:
(2)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 is not met as evidenced by:
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Licensee will ensure all medications are locked and inaccesible to residents by 10/12/2022 POC date.
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LPA observed the facility has medications in the kitchen, and living room areas unlocked and accessible to residents which poses an immediate health, safety, or personal rights risk to 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 Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/12/2022 09:54 AM - It Cannot Be Edited


Created By: Sarah Hurt On 10/11/2022 at 01:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DUTCHOLLOW SUITES I
FACILITY NUMBER: 507004929

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2022
Section Cited
CCR
87309(a)

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87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement is not met as evidenced by: The following requirement has not been met as evidenced by:
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Licensee shall ensure all toxins and chemicals are locked away and send proof to LPA by 10/12/2022 POC date.
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LPA observed toxins, and cleaning supplies unlocked and accesible to residents in several rooms including the garage, kitchen and backyard area of the facility which poses an immediate health, safety or personal rights risk to 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 Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022


LIC809 (FAS) - (06/04)
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