<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515001557
Report Date: 10/23/2024
Date Signed: 10/23/2024 03:19:25 PM

Document Has Been Signed on 10/23/2024 03:19 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:HARVEY CARE HOMEFACILITY NUMBER:
515001557
ADMINISTRATOR/
DIRECTOR:		HARVEY, JANAFACILITY TYPE:
735
ADDRESS:1144 JOSEPHTELEPHONE:
(530) 674-3526
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 6CENSUS: 6DATE:
10/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Kiera DavisTIME VISIT/
INSPECTION COMPLETED:
03:30 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
Licensing Program Analysts Hiratsuka and Mikkelson, conducted this unannounced case management visit in response to Alta California Regional Center issuing a Facility Action Report (FAR) on September 23, 2024.

On September 23, 2024, the Regional Center reviewed the medications for the facility.

The Regional Center issued the FAR for medication dosage discrepancies that LPAs cannot confirm during this visit because the medications have been used up and there are no containers for LPAs to review from that time frame.

The Regional Center issued a FAR because the facility has PRN medication release forms but did not have the dosages, medication names, frequency, and maximum dosage within a 24 hour time frame. Title 22 Regulations does not require PRN authorization forms to be that specific unless the resident cannot self determine but can communicate symptoms clearly or is unable to determine their need for the PRN medication. Review of the resident files shows one resident can communicate their symptoms but not ask for the medication and there were no parameters for the medication as required to Title 22 regulations. This is a violation. The facility has since updated the letters to meet Title 22 Regulations.

The Regional Center issued a FAR because the facility did have a centrally stored medication and destruction log since 2020. This is also a violation of Title 22 regulations. Title 22 Regulations require the log to be maintained for one year at a time. The facility has since started the centrally stored medication and destruction log.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights were provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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 3
Document Has Been Signed on 10/23/2024 03:19 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 10/23/2024 at 03:03 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: HARVEY CARE HOME
FACILITY NUMBER: 515001557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2024
Section Cited
CCR
80075(b)(1)(5)(A)

1
2
3
4
5
6
7
Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration...
1
2
3
4
5
6
7
This was corrected during visit. Licensee has the PRN authorization forms updated to meet Title 22 regulations.
8
9
10
11
12
13
14
There is a written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information. This was not met because the PRN authorization forms did not have the required medication orders.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/23/2024 03:19 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 10/23/2024 at 03:09 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: HARVEY CARE HOME
FACILITY NUMBER: 515001557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2024
Section Cited
CCR
80075(k)(7)

1
2
3
4
5
6
7
Health Related Services. The following requirements shall apply to medications which are centrally stored: The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:
1
2
3
4
5
6
7
This is corrected during visit. The licensee has one for 2024 and is going to continue to have them for up to one year at a time.
8
9
10
11
12
13
14
This was not done as evidence by the licensee not having one for the year 2023 and 2024 until recently.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3