525002771-3-7-2024-59-AS-SBEN-D35TEN-20240307134014

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 525002771
Report Date: 03/07/2024
Date Signed: 03/07/2024 01:40:45 PM

Document Has Been Signed on 03/07/2024 01:40 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:	OLIVE CITY CARE HOME		FACILITY NUMBER:	525002771
ADMINISTRATOR:	MENDROS, MARITES		FACILITY TYPE:	740
ADDRESS:	423 WALNUT STREET		TELEPHONE:	(530) 824-2845
CITY:	CORNING	STATE: CA	ZIP CODE:	96021
CAPACITY:	8	CENSUS: 5	DATE:	03/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Marites Mendros Administrator		TIME COMPLETED:	01:45 PM

NARRATIVE

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03/07/2024 10:00 AM Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Marites Mendros Administrator (cert 6053329740 exp.09-18-23) and explained the purpose of the visit.

LPA Benson and administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to eight (8) resident rooms, common areas, six (6) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet.

The common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The bathrooms were clean and in good repair. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food.

The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguisher fully charged. Smoke detectors are all operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. All employees requiring background checks are cleared. There is a schedule of activities Planned for the clients. All required postings are displayed within the facility.
No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was conducted and documented on 1-1-24, the facility has been conducting drills every 3 months.

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 copy of report and appeal rights were provided to administrator.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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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Document Has Been Signed on 03/07/2024 01:40 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: OLIVE CITY CARE HOME	FACILITY NUMBER: 525002771
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(a)(7)(E)

Other Provisions

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (7) Procedures that address, but are not limited to, all of the following: (E) Storage and preservation of medications, including the storage of medications that require refrigeration. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on 1 bottle of Tyleno PM in resident room, the licensee did not comply with the section cited above in one room out of seven rooms an unattented bottle of tylenol PM, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2024
	Plan of Correction
1 2 3 4	The bottle of Tylenol PM was removed during LPA visit. Staff will check resident rooms daily to remove unattented medication. Staff will commicate with visiting family about medication regulations.

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: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Sarah Benson	TELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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