557005053-6-23-2023-27-AS-KVIA-CT3TWQ-20230623150551

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 557005053
Report Date: 06/23/2023
Date Signed: 06/23/2023 03:06:27 PM

Document Has Been Signed on 06/23/2023 03:06 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:	COMMUNITY COMPASS, INC., THE		FACILITY NUMBER:	557005053
ADMINISTRATOR:	SKIDMORE, RICHARD		FACILITY TYPE:	775
ADDRESS:	19411 SUSAN WAY		TELEPHONE:	(209) 588-1364
CITY:	SONORA	STATE: CA	ZIP CODE:	95370
CAPACITY: 35		CENSUS: 15	DATE:	06/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Michelle Monahan, House Manager		TIME COMPLETED:	01:30 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	06/23/23 Unannounced Annual Inspection visit was made by Licensing Program Analyst, (LPA) Kimberly Viarella to this facility. LPA was met by House Manager, Michelle Monahan. LPA explained the purpose of the visit and asked the staff member to alert the licensee, Richard Skidmore, of Licensing's presence. LPA conducted a brief interview. Census was 15 consumers. The program ran Monday- Friday from 8:00 AM – 3:00 PM. *House Manager received a phone call that the Licensee was in a car accident and was not able to attend. LPA began the inspection in the kitchen. All sharps were locked in drawers and inaccessible to consumers of this adult day program. It was noted that the kitchen had a trash can with a lid, a soap dispenser, and paper towels. Cleaning supplies were locked under the kitchen sink. LPA was shown the pantry where snacks and a food supply for cooking activities was stored. LPA selected random items from the pantry and 7 out of 9 were past the expiration date. LPA inspected the refrigerator and selected 5 random items; 4 out of 5 were past their expiration date. The freezer was also inspected. LPA found 2 packages of ground meat that had damaged packaging. The House Manger apologized and disposed of all expired foods and stated that the pantry and refrigerator would be cleaned as soon as a staff person was available. LPA observed 3 Fire Extinguishers inspected 11/21/2022 Cisco Fire and Sprinkler Inc. The locked laundry room was off the kitchen. The House Manager unlocked the door for the LPA and the locked cabinets inside. The LPA observed toxic cleaners that were inaccessible to consumers. The tour continued through the dining/activities room, living room, multi-purpose room, art room, and exercise room. All rooms had sufficient furniture, lighting and supplies for their designated purposes. The art and exercise rooms were locked, and consumers were always supervised when utilized. Another organization, Supported Living Skills, also had an office on the premises. The House Manager unlocked it so the LPA could view the interior.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

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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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: COMMUNITY COMPASS, INC., THE	FACILITY NUMBER: 557005053
	VISIT DATE: 06/23/2023

NARRATIVE

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LPA inspected 3 bathrooms. All had trash cans with lids, soap dispensers, and paper towels. Hot water temperature was measured and found to be 109 degrees Fahrenheit.

All required signage was posted in the dining/activity room and kitchen. The daily schedule was posted in the dining/activity room. Consumers went out into the community daily for a variety of activities. These included but were not limited to: volunteering at a thrift store, visiting an animal sanctuary, bowling, picnics and more. At the facility the consumers had access to 3 computer stations, over 50 board games/puzzles, art activities, a Wii, a Karaoke machine, movies, and more. The House Manager also unlocked their “store” where prizes were kept that consumers could earn. These prizes included comic books, new T-shirts, hats, action figures, Spiderman accessories and more.

Medications were stored in a locked cabinet in the office. At this time, only one consumer required medication. LPA observed appropriate entries in the log. First Aid kit was inspected and found to be complete.

The LPA inspected the exterior of the facility. LPA noted that all screens were intact, and the walkways were clear of debris. There was a fenced in garden and patio area for the consumers to enjoy. There was one shed on the premises. The House Manager unlocked it for inspection. LPA observed a ladder and other tools and storage items.

LPA reviewed 3 staff files and 3 consumer files. All were complete and contained the required documents.
The following forms and documents were requested to be updated and submitted to CCL via email to kimberly.viarella@dss.ca.gov by 06/30/2023

LIC 308 LIC 500 LIC 610 and updated liability insurance.

According to the California Code of Regulations (Title 22, Division 6), the LPA observed the following deficiency listed on the LIC 809 D.

An exit interview was conducted with the House Manger. Copies of the Facility Evaluation Report and Appeal Rights were provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/23/2023 03:06 PM - It Cannot Be Edited

Created By: Kimberly Viarella On 06/23/2023 at 12:52 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: COMMUNITY COMPASS, INC., THE	FACILITY NUMBER: 557005053
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82076(a)(1)

Food Service: CCR 82076(a)(1) This requirement is not met as evidenced by: (a) In day programs providing ... (1) All food shall be selected, stored, prepared and served in a safe and healthful manner. All meals shall be of the quality and in the quantity necessary to meet the needs of the clients...
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when 7 out of 9 pantry items randomly selected were found past their expiration date and when 4 out of 5 randomly selected items in the refrigerator were found past their expiration date. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that all expired items from the pantry and refrigerator/freezer are disposed. As proof of correction, licensee will submit pictures to kimberly.viarella@dss.ca.gov by 06/30/2023

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

LICENSING EVALUATOR NAME:

Kimberly Viarella

LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC809 (FAS) - (06/04)

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