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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 030317773
Report Date: 08/08/2022
Date Signed: 08/08/2022 01:50:34 PM

Document Has Been Signed on 08/08/2022 01:50 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:JULIE KRAMERFACILITY TYPE:
740
ADDRESS:155 PLACER DRIVETELEPHONE:
(209) 223-4444
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY: 49CENSUS: 33DATE:
08/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Julie Kramer - AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Ruth Wallace and Kesha Lewis arrived at this facility to conduct a unannounced Required 1 Year Annual Inspection Visit. LPA's introduced themselves to Administrator and explained the purpose of the visit. A staff member opened the gate and LPA's were screened for COVID-19 symptoms with temperature at the medication window inside the facility.
 
LPA's and Administrator toured physical plant inside and outside. Ensuring the safety of the residents and compliance with Title 22 regulations. LPA's also conducted the infection control domain tool. The facility has a LIC 808 mitigation plan. LPA's 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. The hot water measured 92.6 *F for room 22, and 94.0 *F for room 32, which 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's 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 extinguishers are current and last inspected on 11/23/2022. The facility has a front porch area that can be utilized for outdoor visits. All emergency exits were clear from obstructions.
LPA's reviewed four (4) staff files. All staff is fingerprint cleared and associated to the facility and staff 1, 2, & 4 do not have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA's reviewed four (4) resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place. LPA's observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.
LPA's requested updated copies via email to LPA Wallace by August 15, 2022: LIC 308 - Designation of Administrator, LIC 309 - Administrative Organization, LIC 610E Emergency Disaster Plan, and Liability Insurance
 Per California Code of Regulations, Title 22, Division 6, one deficiency was observed during this visit and can be found on LIC 809-D. A civil penalty was assessed due to a repeat violation within one year. An exit interview was held with Administrator and a copy of the reports and appeal rights were left at conclusion of visit..
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
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 08/08/2022 01:50 PM - It Cannot Be Edited


Created By: Ruth Wallace On 08/08/2022 at 01:20 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: 08/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 LPA's observation, the licensee did not comply with the section cited above in water temperature was checked in two resident rooms - #22 ( 92.2 F)and (94.0 F) #32 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2022
Plan of Correction
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LIcensee agrees to submit via email to LPA Wallace a month of water temperature logs for section of the building called "long hall". This is the second citation within one year for annual visits, therefore a civil penalty for a repeat violation is being assessed on today's date.
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:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022


LIC809 (FAS) - (06/04)
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