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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317699
Report Date: 11/17/2022
Date Signed: 11/17/2022 01:27:14 PM

Document Has Been Signed on 11/17/2022 01:27 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PRAISE CARE HOMEFACILITY NUMBER:
340317699
ADMINISTRATOR:ARTURO MERCADOFACILITY TYPE:
735
ADDRESS:4600 PARKER AVENUETELEPHONE:
(916) 803-5864
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY: 36CENSUS: 35DATE:
11/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Arturo MercadoTIME COMPLETED:
01:30 PM
NARRATIVE
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On 11-17-22 at 1:00pm, Licensing Program Analyst (LPA) Michael Bilger conducted an unannounced case management visit at facility regarding facility file documentation. LPA met with Administrator Arturo Mercado and explained the purpose of the visit. LPA interviewed Administrator. During resident file reviews and interviews conducted on 11-17-22 , it was determined that an episode of bed bugs occurred in July of 2022 and not reported to licensing per regulatory requirements.

Based on today’s case management, citations are issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Arturo Mercado and a copy of this report was left with Arturo. Appeal rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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 11/17/2022 01:27 PM - It Cannot Be Edited


Created By: Michael Bilger On 11/17/2022 at 12:24 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: PRAISE CARE HOME
FACILITY NUMBER: 340317699

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2022
Section Cited
CCR
80061(b)(1)(E)

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Reporting Requirements (b)Upon the occurrence…of any of the events specified in (1)...a report shall be made to the licensing agency within the agency's next working day…(1) Events reported shall include the following: (E) Any unusual incident…which threatens the physical or emotional health or safety of any client. This requirement was not met as evidenced by:
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Licensee will read regulation 80061 and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview and record review, Licensee did not ensure a report sent to licensing agency after discovery of bed bugs in July of 2022. This poses a potential health, safety, and resident rights risk to residents 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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
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