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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004929
Report Date: 05/11/2023
Date Signed: 05/11/2023 04:09:59 PM


Document Has Been Signed on 05/11/2023 04:09 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 AC/SC, 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: DATE:
05/11/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Cecilia Candido, AdministratorTIME COMPLETED:
04:00 PM
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An office meeting was held today via Microsoft Teams with the Sacramento South Regional Office. The purpose of this meeting is to discuss the Technical Assistance Program (TSP) Engagement Summary. Present in the meeting from the Department were Licensing Program Manager (LPM) Liza King, and Licensing Program Analysts (LPAs) Kimberly Viarella and Jennifer Fain. Representing the facility: the Licensee, Nikolas Adamsson, and Administrator Cecilia Candido. Also present Ombudsman, Melissa Flaherty.

A referral was made to the Departments TSP program following an Informal meeting with the licensee on 10/12/2022. Areas of focus for TSP included: Personal Rights, Medication Management and Physical Plant. During the meeting on this date the Engagement Summary was reviewed, including TSP observations and trainings provided by the Department during the engagement which concluded 02/22/23.

In an effort to come into compliance, the Department has initiated increased monitoring to at least quarterly.

During today’s meeting the licensee agreed to:
In regards to Personal Rights – The licensee agreed to

· conduct Personal Rights Training every 6 months and upon new hire.

In regards to the physical plant the Licensee agreed to

· lean and organize the client/storage room prior to the next quarterly visit, which is now due.
Continued on LIC 809C.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DUTCHOLLOW SUITES I
FACILITY NUMBER: 507004929
VISIT DATE: 05/11/2023
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Licensee reported that they have completed the following since the commencement of the TSP engagement:

· The Facility re-purposed 4 pantry drawers for medication and has secured them with locking mechanisms.
· The pool and chemicals are now secured and inaccessible to residents.
· Administrator has de-cluttered and cleaned the facility.

An exit interview was conducted via telephone and a copy of the report has been provided to the licensee via email, read receipt requested. No citations were issued on this date.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC809 (FAS) - (06/04)
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