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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005717
Report Date: 10/21/2021
Date Signed: 10/21/2021 04:18:06 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/21/2021 04:18 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:KEVINBERG CARE HOMEFACILITY NUMBER:
347005717
ADMINISTRATOR:PARAMO, FERNANDOFACILITY TYPE:
740
ADDRESS:5725 KEVINBERG DRIVETELEPHONE:
(916) 382-9472
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 6DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Estrella ParamoTIME COMPLETED:
03:16 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Estrella and explained the purpose of the visit. Later joined by Administrator Fernando.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 112.9 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 3 resident, during the file review for the residents LPA observed R1 and R2 with outdated Lic 602 both residents have a diagnosis of Dementia and 2 staff files were reviewed during the staff file review LPA observed outdated first aid cards and an outdated Administrator certificate, including criminal record clearances. There was no record of a fire drill.

All staff are Fingerprint cleared and associated to the facility. First aid kit was checked and is complete.

Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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 10/21/2021 04:18 PM - It Cannot Be Edited


Created By: Albert Johnson On 10/21/2021 at 03:24 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: KEVINBERG CARE HOME
FACILITY NUMBER: 347005717

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2021
Section Cited
CCR
87405(a)

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87405(a) All Facilities shall have a qualified and currently certified administrator. This requirement was not met as evidenced by Licensee/Administrator not having current certificate. Expired on 12/27/2020
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Licensee will submit to LPA an updated LIC500 and LIC200 with an employee who has a current administrator certificate and who will act in the administrator capacity until Licensee obtains an updated Administrator certificate. Licensee will send to LPA by end of dayon 10/22/2021
Type B
11/05/2021
Section Cited
CCR
87411(c)(1)

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87411-Personnel Requirements - General-Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. LPA observed licensee / administrator and Estrella's first aid certification to be expired. Based on this the facility is in violation of this section.
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Identified individuals shall obtain a current valid first aid certification. This shall be done within 30 days. Facility shall forward a copies of both individuals first aid certification to the LPA to clear this deficiency.

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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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/21/2021 04:18 PM - It Cannot Be Edited


Created By: Albert Johnson On 10/21/2021 at 03:52 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: KEVINBERG CARE HOME
FACILITY NUMBER: 347005717

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2021
Section Cited
CCR
87705(l)(8)

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87705 (l)(8)-Care of persons with dementia. Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.-There was no documentation that a recent fire drill had been conducted.
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Administrator shall conduct a fire drill and send proof of that a fire drill was conducted to CCL by the POC due date.
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021


LIC809 (FAS) - (06/04)
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