507005604-8-18-2023-27-AS-KVIA-CUKVEP-20230810162239

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507005604
Report Date: 08/10/2023
Date Signed: 08/18/2023 03:56:28 PM

Document Has Been Signed on 08/18/2023 03:56 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:	ASTORIA AT OAKDALE		FACILITY NUMBER:	507005604
ADMINISTRATOR:	JACQUELINE HERNANDEZ		FACILITY TYPE:	740
ADDRESS:	700 LAUREL AVE		TELEPHONE:	(209) 847-0864
CITY:	OAKDALE	STATE: CA	ZIP CODE:	95361
CAPACITY:	45	CENSUS: 37	DATE:	08/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jacqueline Hernandez, Designated Facility Administrator		TIME COMPLETED:	04:45 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 08/10/2023 unannounced annual inspection was made to this facility by Licensing Program Analyst (LPA) Kimberly Viarella. The LPA identified herself and the purpose of the visit and asked to speak to the Designated Facility Administrator. LPA met Jacqueline Hernandez, (Certification # 6058692740, expired 02/11/2023 and provided proof of recertification) the Designated Facility Administrator and a brief interview followed. The tour began with resident accommodations. Rooms were clean and had adequate furniture and lighting. Each room had a private bathroom where grab bars and non-skid shower surfaces were observed. LPA observed toxins and personal hygiene items that were not approved of in the resident’s LIC 602. Staff immediately removed these items. The kitchen was inaccessible to residents and the LPA observed 7 days of non-perishable and 2 days of perishable food supplies. Upon inspecting the pantry, the LPA observed items that were opened, not dated and/or expired. The LPA also observed expired items in the reach-in refrigerator. The Designated Facility Administrator immediately disposed of the items. LPA observed smoke and carbon monoxide detectors throughout the facility and fire extinguishers were last inspected in 04/18/2023 by Jorgenson Co. The hot water temperature was measured at 107.6 degrees Fahrenheit and was in compliance. The LPA toured the medication room which was locked and kept inaccessible to residents in care. Policies and procedures were discussed and the EMAR system and logs were reviewed. Medications, including narcotics were kept in a locked cart and distributed to residents on an individual basis as directed by their physicians. Primary pharmacy was Premier, which does not offer audits as part of their service, but

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

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 4

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: ASTORIA AT OAKDALE	FACILITY NUMBER: 507005604
	VISIT DATE: 08/10/2023

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
26
27
28
29
30
31
32

audits were conducted monthly and quarterly by internal staff. First Aid kit was also reviewed to ensure compliance.

LPA observed residents participating in activities in both the Assisted Living and Memory Care areas. Assisted Living conducted painting classes outdoors as well as Bingo inside after lunch. In Memory Care, the LPA witnessed Caregivers playing card games and board games. The schedule of activities were displayed on a monitor as well as provided in print for residents in care.

LPA inspected the exterior of the facility including locked outbuildings that contained maintenance equipment and holiday decorations. There were no bodies of water present. All residents had access to covered outdoor spaces, with Memory Care being completely enclosed for safety purposes.

LPA completed a file review of 9 resident files, all were complete and contained the required information. LPA also reviewed 5 employee files and they too were in compliance at this time.

According to the California Code of Regulations, Title 22, the following deficiencies were observed and cited on the LIC 809 D page.

A copy of this report was provided to the Designated Facility Administrator along with the Appeal Rights.

Exit interview.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 08/18/2023 03:56 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: ASTORIA AT OAKDALE	FACILITY NUMBER: 507005604
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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 liquid hand soap in common areas as well as in bathrooms of dementia care residents. This LPA also observed denture cleaning solution in a Memory Care resident's bathroom. These items pose an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/11/2023
	Plan of Correction
1 2 3 4	Designated Administrator shall create a schedule for sweeps that will take place 3X a week where Carestaff will remove toxins and prohibited items from Memory Care. This scheduled will be submitted to CCL at Kimberly.viarella@dss.ca.gov by the close of business 09/11/2023.

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	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 08/18/2023 03:56 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: ASTORIA AT OAKDALE	FACILITY NUMBER: 507005604
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)(1)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when the LPA observed crumbs, stains, and sticky surfaces on appliances, shelves, cabinets, and floor in the facility kitchen. This was unsanitary and poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/23/2023
	Plan of Correction
1 2 3 4	Facility Administrator shall schedule staff to deep clean the kitchen and will develop a regular cleaning schedule to maintain a sanitary environment. This schedule and pictures of the cleaned kitchen shall be submitted to Kimberly.viarella@dss.ca.gov by 08/23/2023.

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when the LPA observed uncovered, unlabeled an/or expired food items in both the pantry and refrigerator. These items included: mayonnaise, salad dressing, baking soda, cocoa powder, and graham crackers. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/23/2023
	Plan of Correction
1 2 3 4	Facility Administrator shall schedule staff to purge the pantry and refrigerators/freezers of any expired or damaged food items. The Administrator will develop a schedule for staff to inspect and review expiration dates and packaging on a regular basis in order to maintain a sanitary environment. This schedule shall be submitted to Kimberly.viarella@dss.ca.gov by 08/23/2023.

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	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4