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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005500
Report Date: 04/15/2022
Date Signed: 04/19/2022 02:45:32 PM

Document Has Been Signed on 04/19/2022 02:45 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:HUMMINGBIRD COURT CARE HOMEFACILITY NUMBER:
507005500
ADMINISTRATOR:ESCORIDO, ROSELYNFACILITY TYPE:
735
ADDRESS:3124 HUMMINGBIRD CTTELEPHONE:
(209) 577-5830
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 4DATE:
04/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Roselyn Escorido TIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Licensee Roselyn Escorido Continual Administrator's Certification for Administrator Astrofel Escorido expires May 10, 2022. There are currently 4 clients residing at this home. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

LPA did observe a prescription medication bottle mislabeled in a residents bedroom.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 118 degrees. Toxins and cleaning supplies are locked and inaccessible, first aid kit is accessible and complete. LPA verified staff working is background cleared. Licensee provided vaccine cards for all facility staff working.

The following deficiencies were observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610 the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Licensee Roselyn Escorido and copy of report left at facility
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2022
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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Document Has Been Signed on 04/19/2022 02:45 PM - It Cannot Be Edited


Created By: Sarah Hurt On 04/15/2022 at 03:06 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: HUMMINGBIRD COURT CARE HOME
FACILITY NUMBER: 507005500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(7)
80075(7) Health and related services. For every prescription and non prescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the clients file and a label on the medication. Both the physicians order and the label shall contain at least all of the following medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as LPA observed bottle in residents room labeled VITAMIN D2 50,000IU. The facility staff informed LPA the bottle is mislabeled and actually contained PRN docusate sodium which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2022
Plan of Correction
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Licensee will conduct training on resident medications for all facility staff and provide proof to LPA by 04/25/2022 POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022


LIC809 (FAS) - (06/04)
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