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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005500
Report Date: 05/23/2024
Date Signed: 05/23/2024 01:22:57 PM

Document Has Been Signed on 05/23/2024 01:22 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:HUMMINGBIRD COURT CARE HOMEFACILITY NUMBER:
507005500
ADMINISTRATOR/
DIRECTOR:		ESCORIDO, ROSELYNFACILITY TYPE:
735
ADDRESS:3124 HUMMINGBIRD CTTELEPHONE:
(209) 577-5830
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 5DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Roselyn EscoridoTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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On 5/23/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required on year annual visit. LPA Jensen met with Administrator Roselyn Escorido and explained the purpose of today's visit. The facility currently has 5 clients however one is moving out tomorrow. There was a power outage during the course of this annual inspection and power was restored by the end of the inspection. Based on an interview with the Administrator they do not have a formal written plan to be self reliant for 72 hours in the event of an emergency. The Licensee does have additional facilities in Modesto and Stockton that can be used for relocation if needed

LPA Jensen toured the grounds. The facility has a shaded backyard area and patio furniture available for outdoor activities. All window screens were observed to be in good repair. There is a broken dishwasher being stored in the backyard by the deck. The backyard gate door is sagging and must be lifted to close.

LPA Jensen toured the interior physical plant. While writing this report LPA Jensen observed a cockroach on the kitchen wall. The kitchen has an open container for waste disposal under the kitchen sink. In speaking with clients it was confirmed that the cockroach problem has been an ongoing issue. There was an adequate food supply observed. All knives, medications and toxins were observed to be locked and inaccessible to residents in care. The resdient shared bathroom water temperature was measured at 117 degrees and is in compliance. There is a gap/hole in the wall where the vanity meets the wall that is need of repair. There is an inoperable outdoor water sprinkler system control unit next to the kitchen with a broken cover that should be removed. There is an adequate supply of linens. The bedrooms contained dressers, night stands and lamps but no chairs. There are no night lights in the hallways. The bedroom wall for Resident 1 (R1) had stains and requires cleaning or painting.

The fire extinguisher was last serviced in May of 2024 and is in compliance. The smoke detector and carbon monoxide detector were tested and determined to be in good working order. There is an emergency supply of food, water and emergency lighting.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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: HUMMINGBIRD COURT CARE HOME
FACILITY NUMBER: 507005500
VISIT DATE: 05/23/2024
NARRATIVE
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LPA Jensen requested a copy of the liability insurance, LIC 500 and LIC 308 to be emailed by 5/30/24.

There are currently 2 direct care staff members. LPA Jensen reviewed 2 of 2 care staff files and determined them to be complete and in compliance. LPA Jensen reviewed 5 of 5 client files and determined them to be complete and in compliance. Technical assistance was provided based on 2 of 5 clients being over the age of 59. LPA Jensen interviewed 2 of the 3 clients and a staff member. LPA Jensen conducted a random audit of P&I funds and determined the accounting to be accurate.

The inspection tool was used during the course of this inspection. Deficiencies are being cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6.

An exit interview was conducted and a copy of this report, the confidential names list and appeal rights were provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 05/23/2024 01:22 PM - It Cannot Be Edited


Created By: Maja Jensen On 05/23/2024 at 01:03 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HUMMINGBIRD COURT CARE HOME
FACILITY NUMBER: 507005500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)(1)
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. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's observation of a cockroach on the kitchen wall which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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The Licensee contacted a pest control agency in the presence of the LPA and they are scheduled to perform service tomorrow, 5/24/24 at 11am. The Licensee will submit the service report to the Department.
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:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 05/23/2024 01:22 PM - It Cannot Be Edited


Created By: Maja Jensen On 05/23/2024 at 01:03 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HUMMINGBIRD COURT CARE HOME
FACILITY NUMBER: 507005500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024

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
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Based on LPA Jensen's observation of a sagging gate door, stained wall, hole in the bathroom wall and inoerable dishwasher in the backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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The Licensee agrees to repair the gate door, bathroom wall, remove the inoperable appliance from the property and paint the bedroom by the Plan of Correction due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024


LIC809 (FAS) - (06/04)
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