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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 030317773
Report Date: 08/20/2021
Date Signed: 08/20/2021 01:15:08 PM

Document Has Been Signed on 08/20/2021 01:15 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:AMADOR RESIDENTIAL CARE FACILITYFACILITY NUMBER:
030317773
ADMINISTRATOR:FLETA HERNDONFACILITY TYPE:
740
ADDRESS:155 PLACER DRIVETELEPHONE:
(209) 223-4444
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY: 49CENSUS: 22DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Brianna CaswellTIME COMPLETED:
01:14 PM
NARRATIVE
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On 08/20/21 at 11:18 AM, Licensing Program Analyst (LPA) Christina Valerio arrived at this facility unannounced to conduct an annual inspection visit. LPA Valerio introduced herself, explained the purpose of the visit, and was met by facility staff Brianna Caswell. LPA Valerio called prior to entering the facility. A staff member opened the gate and LPA was screened for COVID-19 symptoms with temperature at the medication window inside the facility.
 
The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. LPA also conducted the infection control domain tool. The facility has a LIC 808 mitigation plan. LPA observed the facility to have COVID-19 informational signs posted throughout the facility. The facility is able to designated and dedicated a COVID-19 bedroom, bathroom, and isolation area if needed.
LPA observed the temperature inside the facility was measured at 74*F. The hot water was measured at 122 *F for room 24, 121.6 *F for room 22, 117.8 *F for room 38, and 111.6 *F for room 10. Room 24 and Room 22, was not within the regulatory range of 105 - 120 degrees F. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area, cleaning supplies, and sharps to be locked and inaccessible to clients. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher is up to date with last check on 11/19/2020. The facility has a front porch area that can be utilized for outdoor visits. All emergency exits were clear from obstructions. LPA requested updated copies of documentation: LIC 500 personnel report, LIC 610E Emergency Disaster Plan, and Liability Insurance
 
Per California Code of Regulations, Title 22, Division 6, deficiencies were observed during this visit and can be found on LIC 809-D. An exit interview was held and a copy of the report was left.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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 08/20/2021 01:15 PM - It Cannot Be Edited


Created By: Christina Valerio On 08/20/2021 at 12:58 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: AMADOR RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 030317773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in out of 2 out of 6 individual resident bathrooms checked, which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/21/2021
Plan of Correction
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Licensee had maintence staff adjust the water temperatures for the long hall bedrooms. Licensee will send a picture of water reading within regulatory range to LPA Valerio at christina.valerio@dss.ca.gov by POC date. Licensee will continue to monitor water temperatures and maintain a water log to record temperature.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2021


LIC809 (FAS) - (06/04)
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