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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004929
Report Date: 02/13/2024
Date Signed: 03/15/2024 01:41:20 PM


Document Has Been Signed on 03/15/2024 01:41 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 IFACILITY NUMBER:
507004929
ADMINISTRATOR:CANDIDO, CECILIAFACILITY TYPE:
740
ADDRESS:4112 LAURANT COURTTELEPHONE:
(209) 521-0566
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 2DATE:
02/13/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Cecelia Candido and Nikolas AdamssonTIME COMPLETED:
05:00 PM
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A Non-Compliance Conference (NCC) was conducted on this day, 2/13/24, by the Sacramento South Regional Office via Microsoft Teams. The purpose of this NCC meeting was to discuss the continued non-compliances and serious deficiencies observed while the facility has been undergoing increased monitoring. Present at the meeting were Regional Manager (RM), Stephenie Doub, Licensing Program Manager (LPM), Lisa Rios, Licensing Program Analyst (LPA), Maja Jensen, Licensees/Administrators, Cecelia Candido, and Nikolas Adamsson. The Non-Compliance Conference process was explained during this meeting to include the administrative process.

An informal meeting was held on 10/12/22 to discuss concerns in the areas of: food service, medications accessible to residents, chemicals accessible to residents, knives accessible to residents, maintaining the facility in good repair and personal rights. As a result, increased monitoring was initiated and the Licensee engaged in the Technical Support Program. Over the course of the past year, the Department has continued to observe non-compliance in aforementioned areas of concern.

Items discussed during the Non-Compliance Conference were:



· Safe medication storage and administration
· Storage of hazardous items
· Fire Clearance compliance, adherence to facility sketch (LIC 9099)
· Reporting Requirements and communication with the Department
· Prohibited/restricted health conditions
· Care Plans

Continued on LIC 809C....
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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: 02/13/2024
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During the meeting the Licensee agreed to do the following:

· Conduct and maintain logs of weekly facility inspections to ensure hazardous items and medication are secured with logs to be sent to the Department by 3/1/24

· Staff training regarding protocols for restricted/prohibited health conditions and safe storage of hazardous items due by 3/1/24

· Facility will document the date a medication was started

Completing the non-compliance conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.



In the event that the Department determines that the licensee has violated the law/regulations or is inadequately implementing the approved plans, the Department, in its discretion, may seek formal legal action or other appropriate administrative action.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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