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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 030317773
Report Date: 02/09/2023
Date Signed: 02/09/2023 11:50:43 AM

Document Has Been Signed on 02/09/2023 11:50 AM - 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: 30DATE:
02/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Facility StaffTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit. LPA met with facility staff, and explained the purpose of the visit. The facility added a memory care section in the facility when their sister facility, Jackson Gardens, closed in 2022.

In order to serve residents with dementia, the facility must have a dementia care plan on file and comply with Title 22 regulations. The facility has been licensed since 08/25/1993. Their license stated the facility is licensed for: Age Range 60 and over. 49 ambulatory and non-ambulatory. Approval for 10 hospice residents at a time. Approved Plan of Operation for Total Care on File. Client group served: Elderly

In order to confirm the facility is able to meet the needs of residents with dementia, LPA obtained a dementia care plan dated for year 2022. During the visit, LPA checked the following:
    · Facility has non-ambulatory fire clearance for each room for residents with Dementia
    · Updated Emergency Disaster Plan that addresses safety of residents with Dementia
    · Ensuring that there is adequate number of staff to supper residents needs per appraisal
    · Inaccessibility of devices or appliances that could harm a resident with Dementia
    · Inaccessibility of objects such as weapons, medication, cleaning supplies, etc,.

During the tour today, there was 2:6 ratio for the memory care side of the facility. LPA did not observe devices or appliance that may harm a resident with dementia. LPA observed medications and cleaning supplies inaccessible to residents. LPA discussed information with Administrator Fleta via cell phone. LPA conducted an exit interview with facility staff, and provided a copy of the report.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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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