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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004929
Report Date: 08/02/2023
Date Signed: 08/02/2023 12:00:31 PM


Document Has Been Signed on 08/02/2023 12:00 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: 3DATE:
08/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cecilia CandidoTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to conduct a case management visit regarding the plan of correction from complaint 27-AS-20230616122253 . LPA was greeted by licensee and explained the reason for the visit.

Licensee was to complete a plane of correct that included Providing a refund to R1 with in 3 days which was completed, additionally the license was to update all admissions agreements with required information for all residents and provide a copy to the department via the LPA by 7/24/2023. updates can be emailed to LPA Lewis at Kesha.Lewis@dss.ca.gov this was not completed.

Copies are now due by 08/11/2023.


Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies cited during this visit are listed on the attached 9099D. Appeal rights given.

Exit interview.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
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 2


Document Has Been Signed on 08/02/2023 12:00 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: DUTCHOLLOW SUITES I
FACILITY NUMBER: 507004929

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2023
Section Cited
CCR
87507(5)(g)(c)

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Refund conditions.
Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652. dmission agreements shall specify the following:
(1) Basic services, as defined in Section 87101(b), to be made available. (2) Additional items and services which are available. (3) Payment provisions
A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.
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Provided a refund to R1 with in 3 days. LPA provided the licensee with the phone number where R1 could be reached as discussed with R1. Licensee will also update all admissions agreements with required information for all residents and provide a copy to the department via the LPA by 7/24/2023. updates can be emailed to LPA Lewis at
Kesha.Lewis@dss.ca.gov

Copies are now due by 08/11/2023.
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Based on records review and interviews with R1 and the ombudsmen (ON) LPA reviewed the admissions agreement , the licensee did not comply with the section cited. After a review of resident records LPA found that the admissions agreement only had N/A under refunds and no other information which poses a potential health, safety or personal rights risk to persons 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
LIC809 (FAS) - (06/04)
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