507004929-9-25-2024-27-AS-MJEN-D9FV27-20240925160237

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004929
Report Date: 09/25/2024
Date Signed: 09/25/2024 04:02:48 PM

Document Has Been Signed on 09/25/2024 04:02 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:	09/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Cecelia Candido		TIME COMPLETED:	04:15 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 9/25/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a one year annual inspection. LPA Jensen met with Administrator Cecelia Candido and explained the purpose of today's visit. The current census is 3. LPA Jensen toured the grounds and observed the paths to be free of obstruction. The facility has a swimming pool that was observed to be locked and inaccessible to residents. The front side yard has numerous bags of items for disposal waiting to be picked up. The Administrator advised that the debris form the side yard will be removed by 9/26/24. LPA Jensen toured the interior of the facility. LPA Jensen observed the facility to be adequately furnished and free of odor. There are 4 bedrooms, 3 of which are designated for client use. LPA Jensen observed 1 client room being used for storage. The Licensee has agreed to submit an LIC 200 with a request to reduce capacity to 4 with the intention of designating 2 of the 4 bedrooms for clients and both client bedrooms will be double occupancy. The fire extinguisher was purchased on October of 2023 and is in compliance. The smoke detectors and carbon monoxide detectors were determined to be in good working order. The water temperature was tested in the hallway bathroom and was determined to be in compliance. The facility maintains several first aid kits. Knives, toxins and medications were observed to be locked and inaccessible to residents in care. LPA Jensen inspected the kitchen and observed a 2 day supply of perishable food and a 7 day supply of non-perishable food. Several food items that require refrigeration after opening were observed in the kitchen cupboards. The food items had been opened but were not refrigerated. Several dry food items were observed that had been removed out of there original packaging and put in to containers with no dates or labels. LPA Jensen observed medications to be removed from their original packaging and transferred to alternate containers for AM and PM medication passes.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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: 09/25/2024

NARRATIVE

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LPA Jensen reviewed resident files. It was observed that 1 of 3 resident admission agreements stated no refund upon death. The Licensee revised the admission agreement and and had the resident sign the new agreement in the presence of the LPA. Technical assistance was provided. It was observed that 1 of 3 resdient's had an outdated LIC 602 (physician's report). The LIC 602 was from the year 2022.

At this time the Administrator/Licensee and Co-Administrator are live-in and the only staff. Cecelia Candido's Administrator certificate expired in June of 2024 and her renewal application was submitted in May. A copy of the liability insurance was obtained and remains current.

LPA Jensen interviewed 2 of 3 residents who both advised they are satisfied with all aspects of care. 1 of 3 residents was sleeping for the entirety of the visit.

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 was provided.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 09/25/2024 04:02 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: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Jensen's record review, the licensee did not comply with the section cited above in 1 out of 3 residents files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/16/2024
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC809 (FAS) - (06/04)

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