507005500-5-8-2023-27-AS-KVIA-CRMUR5-20230508154811

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507005500
Report Date: 05/08/2023
Date Signed: 05/08/2023 03:48:24 PM

Document Has Been Signed on 05/08/2023 03:48 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:	HUMMINGBIRD COURT CARE HOME		FACILITY NUMBER:	507005500
ADMINISTRATOR:	ESCORIDO, ROSELYN		FACILITY TYPE:	735
ADDRESS:	3124 HUMMINGBIRD CT		TELEPHONE:	(209) 577-5830
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY: 6		CENSUS: 5	DATE:	05/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Roselyn Escorido		TIME COMPLETED:	04:00 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 05/08/23, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced annual inspection to this facility. LPA identified herself upon arrival and stated the purpose of her visit. LPA met with designated facility administrator, Roselyn Escorido (Administrator's Certificate # 6008620735, expiration date 10/02/23) and interviewed her briefly. At the time, census was 5. LPA toured the facility including but not limited to: the kitchen/dining area, living room, 4 resident bedrooms, 2 staff rooms, 2 bathrooms, laundry room as well as the exterior grounds. The tour began in the kitchen. The LPA had the staff open all the drawers and cabinets. LPA observed a large 6 inch chef's knife in a drying rack on the counter and another sharp knife in an unlocked drawer. LPA explained that this posed an immediate threat to residents in care. Staff secured the items in a locked cabinet. The LPA inspected the refrigerator and pantry and found the food supply was adequate for 2-day perishable and 7-day nonperishable. The LPA noted that the fire extinguisher was inspected on 05/02/23 by Nor Cal Fire Inc. LPA then tested the hot water in the bathroom adjacent to the kitchen. It measured 113 degrees Fahrenheit, within the required range of 105-120 degrees. The bathroom had paper towels for residents to use and was otherwise in compliance. The LPA found the laundry room unlocked and toxins on the floor. This posed an immediate threat to residents in care. Staff immediately locked the door and returned to compliance. LPA observed 4 resident bedrooms and found them all to be in compliance with the required furniture, (Continued on LIC 809C.)

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

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: HUMMINGBIRD COURT CARE HOME	FACILITY NUMBER: 507005500
	VISIT DATE: 05/08/2023

NARRATIVE

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furnishings and lighting. The second bathroom was also in compliance and the linen cabinet contained a sufficient amount of bedding for the residents in care at this time.

LPA observed resident medications were stored in a locked cabinet in the kitchen. Policies and procedures regarding administration and storage were reviewed. LPA inspected the First Aid kit and found it to contain all the required elements.

The tour continued into the backyard. There were 2 sheds, both with unlocked locks that hung off the doors. The gray shed on the left had a door that did not function properly and was in need of repair. LPA observed one section of the fence, behind the shed on the right hand side of the yard, was falling down. There were 5 trash cans and 3 contractor sized trash bags of empty bottles/cans. There was an odor present. LPA observed other trash and debris in the yard, including cardboard and garden equipment.

LPA conducted a staff and resident file review. 3 out of 4 residents had files that were complete and up to date. 1 resident required and updated Needs and Services plan. All staff records reviewed were in compliance.

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

LPA requested the following documents:
LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 610 the Emergency Disaster Plan
Copy of current Administrator’s Certificate to update the facility file
Copy of Liability Insurance

Listed documents shall be sent to Licensing at Kimberly.viarella@dss,ca,gov

Exit interview conducted with Designated Facility Administrator, Roselyn Escorido and copy of report and Appeal Rights were left at the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/08/2023 03:48 PM - It Cannot Be Edited

Created By: Kimberly Viarella On 05/08/2023 at 02:48 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: 05/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above when the LPA observed toxins and cleaning solutions on the floor of the unlocked laundry room floor. LPA also noted 6 inch chef's knife in the drying rack on the kitchen counter and when the LPA found a second sharp knife in an unlocked drawer in the kitchen. These items posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2023
	Plan of Correction
1 2 3 4	All toxins and other items that could pose a danger (knives) shall be kept secured and inaccessible to residents in care. Licensee will post a sign on the laundry room door reminding staff to lock upon exiting. Knives will be moved to a locked cabinet or drawer. Photos of the sign and new location for the knives will be sent to Community Care Licensing at kimberly.viarella@dss.ca.gov by 5/9/2023.

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:

Liza King

LICENSING EVALUATOR NAME:

Kimberly Viarella

LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/08/2023 03:48 PM - It Cannot Be Edited

Created By: Kimberly Viarella On 05/08/2023 at 02:48 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: 05/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above when the LPA observed 5 trash cans and 3 trash bags of empty bottles and cans in the back yard along with a broken fence and 2 sheds in disrepair; 1 filled with trash and debris. This posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	The licensee will develop a plan for making the necessary repairs and yard clean-up and submit it to Community Care Licensing at kimberly.viarella@dss.ca.gov by the above date.

Type B

Section Cited

CCR

85068.3(a)

Modifications to Needs and Services Plan

(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review the licensee did not comply with the section cited above when the LPA observed the most recent IPP for a resident in care dated 1999. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	The licensee will contact the regional center to schedule an appointment with the appropriate party to conduct a new needs and services plan. Community Care Licensing will be contacted with the date of this appointment by emailing kimberly.viarella@dss.ca.gov by the above date.

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 King

LICENSING EVALUATOR NAME:

Kimberly Viarella

LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC809 (FAS) - (06/04)

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