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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515001365
Report Date: 05/17/2022
Date Signed: 05/17/2022 05:19:54 PM


Document Has Been Signed on 05/17/2022 05:19 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:GARDENS, THEFACILITY NUMBER:
515001365
ADMINISTRATOR:PICKARD, CAROLFACILITY TYPE:
740
ADDRESS:840 WASHINGTON AVENUETELEPHONE:
(530) 790-3075
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:49CENSUS: 18DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Carol Pickard, AdministratorTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Mai Thao and Talwinder Bains arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain on today's date. LPAs met with Carol Pickard, Administrator and Jamie Scott, Nurse Manager. LPAs explained the purpose of the visit. Prior to initiating the annual inspection, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 In addition, Staff screened LPA prior to entering the facility.

The current census for today is 18. Areas toured include but are not limited to: common area, resident bedroom, bathrooms, dining room, and activity room. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and Licensee completed the infection control domain during this inspection.

At approximately 3:12pm, LPAs, Nurse Manager and Staff 1 (S1) reviewed 5 of 5 resident Centrally Stored Medication (CSM). LPAs, Nurse Manager, and Staff observed these CSM not entered in the Centrally Stored Medication Logs: Resident 1 (R1) has 7 CSM, Resident 2 (R2) has 1 CSM, Resident 3 (R3) has 5 CSM, and Resident 4 (R4) has 2 CSM. Administrator stated that facility has been without a nurse for a while and has not conducted audit on CSM to ensure that they are entered in CSM logs accurately.

At approximately 5:01pm, LPAs, Administrator, and Nurse Manager observed Resident 5 (R5) without a sign admission agreement on file.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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 05/17/2022 05:19 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: GARDENS, THE
FACILITY NUMBER: 515001365

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes (A)-(F).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above in 4 out of 4 residents Centrally Stored Medications (CSM) were not entered in the CSM logs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2022
Plan of Correction
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Licensee agrees to entered in Centrally Stored Medications in CSM logs and submit in copies to Licensing by 5/17/2022. Licensee agrees to hold training with staff and submit in signature of attendance to Licensing by 5/24/2022.
Type B
Section Cited
CCR
87507(c)
87507 Admission Agreements (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interivews], the licensee did not comply with the section cited above in 1 out of 1 resident, R5 did not have a signed and dated admission agreement on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2022
Plan of Correction
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Licensee agrees to submit in sign admission agreement to Licensing by 5/24/2022

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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2