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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 517003360
Report Date: 02/05/2025
Date Signed: 02/05/2025 11:50:45 AM

Document Has Been Signed on 02/05/2025 11:50 AM - 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:WILFREDO A. CHICO'S HOMEFACILITY NUMBER:
517003360
ADMINISTRATOR/
DIRECTOR:		CHICO, WILFREDO A.FACILITY TYPE:
735
ADDRESS:1583 COUNTRYSIDE DRIVETELEPHONE:
(530) 755-1579
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY: 6CENSUS: 6DATE:
02/05/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Joanna MelendresTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 02/05/2025, Licensing Program Analyst (LPA) Ivan Avila arrived at the facility to conduct an unannounced case management visit in response to Alta California Regional Center issuing a Facility Action Report (FAR) on 01/29/2025. LPA met with Joanna Melendres and explained the purpose of the visit.

LPA Avila reviewed the documented visit conducted by Alta California Regional Center and observed that the report stated on 01/29/2025, the Regional Center reviewed the medications records for the residents and reviewed staff files.

The Regional Center issued a Facility Action Report (FAR) because the facility has a resident who is diabetic and the facility staff did not have a written health care plan for the resident that includes but not limited to: blood sugar monitoring, target blood sugar ranges, critical levels requiring attention, and clear instructions to staff on responding to dangerously high or low blood sugar. This is a violation. Licensee shall submit a written plan of correction on how they shall ensure there are written care plans addressing the specific needs of the individual. The care plans themselves shall not be submitted, what shall be submitted is how the licensee shall ensure the regulations are met.

The Regional Center issued a FAR because the facility did not administer a medication to a resident for the month of December 2024 to January 13, 2025.

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.

An exit interview was conducted, and a copy of the report and appeal rights were provided.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Ivan Avila
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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 02/05/2025 11:50 AM - It Cannot Be Edited


Created By: Ivan Avila On 02/05/2025 at 10:22 AM
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: WILFREDO A. CHICO'S HOME
FACILITY NUMBER: 517003360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2025
Section Cited
CCR
80075(b)

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80075(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidence by:
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Licensee has completed the corrective action plan with ACRC. Licensee developed a plan to ensure medications are refilled timely. Licensee will submit updated plan to LPA by 02/06/2025.
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Based on record review, the licensee did not comply with the section cited above as client did not receive medication for a month, which possesses an immediate Health, Safety, and Personal Rights risk to persons in care
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Type A
02/06/2025
Section Cited
CCR80092.2(a)(1)

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80092.2(a)(1) The licensee shall develop and maintain a written Restricted Health Condition Care Plan...(1) Documentation that the...client's physician or a licensed professional designated by the physician, and the placement agency, if any, participated in the development of the plan. This requirement is not met as evidence by:
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Licensee has completed the corrective action plan with ACRC. Licensee updated the resident's restricted health condition care plan. Licensee will submit updated plan to LPA by 02/06/2025.
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Based on record review, the licensee did not comply with the section cited above as client did not have a written care plan by a licensed professional, which possesses an immediate Health, Safety, and Personal Rights risk to persons in care.
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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:Anthony Perez
LICENSING EVALUATOR NAME:Ivan Avila
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/05/2025 11:50 AM - It Cannot Be Edited


Created By: Ivan Avila On 02/05/2025 at 10:33 AM
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: WILFREDO A. CHICO'S HOME
FACILITY NUMBER: 517003360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2025
Section Cited
CCR
80092.8(a)(1)

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80092.8(a)(1) A licensee of an adult CCF may accept or retain a client who has diabetes if all of the following conditions are met: (1) The licensee is in compliance with Section 80092.1. This requirement is not met as evidence by:
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Licensee has completed the corrective action plan with ACRC. Licensee developed a plan to monitor resident's restricted health condition. Licensee will submit updated plan to LPA by 02/06/2025.
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Based on record review, the licensee did not comply with the section cited above as client did not have their diabetes blood sugar monitored, which possesses an immediate Health, Safety, and Personal Rights risk to persons in care.
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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:Anthony Perez
LICENSING EVALUATOR NAME:Ivan Avila
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
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