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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 11:49:37 AM

Document Has Been Signed on 02/09/2023 11:49 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 - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Facility staffTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit to follow up on various incident reports received. LPA met with facility staff, and explained the purpose of the visit.

Resident 1 (R1) had a fall, which results in R1 landing on R1's back. R1 was sent out to Sutter Amador Hospital. According to staff, R1 returned with no major injuries. Facility records show follow up care was provided and R1 was monitored.

The Regional Office received a death report for Resident 3(R3). The death report did not include cause of death or conditions related to death. LPA reviewed resident records and interviewed staff. LPA discussed with ADM Fleta regarding the completion of a death report. LPA to provide TA to assistant administrator Karly.

An incident occurred wit Resident 4 (R4) and Resident 5 (R5). R4 was walking down the hall and walked by R5. R5 used an elbow and forearm to push R4, which resulted in R4 falling on the ground hitting R4's head. All responsible parties were contacted, in addition to the non-emergency and local PD. R4 sustained an injury of head; laceration of forehead. R4 was made a follow up appointment to have sutures removed. According to staff,

Per California Code of Regulations (CCR), Title 22, deficiencies are being cited on LIC 809-D. Appeal Rights provided. Failure to correct deficiencies may result in civil penalties. An exit interview held, and a report was provided to facility staff. LPA also discussed information with Administrator Fleta Herndon via cell phone.
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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Document Has Been Signed on 02/09/2023 11:49 AM - It Cannot Be Edited


Created By: Christina Valerio On 02/09/2023 at 09:02 AM
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: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2023
Section Cited
CCR
87468.1(a)(3)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, ...This requirement was not met as evidenced by:
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Licensee stated staff have increased monitoring, are continuing to communicate with third party/responsible party, and will provide additional in-service training to staff. LPA to receive supportive documentation by POC due date.
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Based on records review, the licensee did not ensure R4 was free from abuse while in the care and supervision of the facility, which poses an immediate health and safety 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:Stephen Richardson
LICENSING EVALUATOR NAME:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023


LIC809 (FAS) - (06/04)
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