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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 030317773
Report Date: 07/27/2023
Date Signed: 07/27/2023 02:46:01 PM

Document Has Been Signed on 07/27/2023 02:46 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:KARLY STURGEONFACILITY TYPE:
740
ADDRESS:155 PLACER DRIVETELEPHONE:
(209) 223-4444
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY: 49CENSUS: 29DATE:
07/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Karly Sturgeon TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit. LPA met with facility staff Hanna, and explained the purpose of the visit. LPA was later met by Administrator Karly Sturgeon. LPA followed up on 2 incident reports, 1 death report, and provided information on an exception request.

An incident occurred with Resident 1 (R1) where R1 had an unwitnessed fall and was found by staff on the floor with blood. R1 was transported to the hospital and returned with no new orders. R1 was placed on fall monitoring and the facility implemented the chair monitor. LPA observed the chair monitor locate do on the wheel chair. There is a clip that gets attached to R1's shift collar and if R1 gets up, the alarm will sound.

An incident occurred with Resident 2 (R2) where R2 had an unwitnessed fall and was found on the floor by staff. R2 was observed to have skin tears on elbow and forehead. R2 was evaluated by the hospice nurse. R2 was put on alert charting and has a chair alarm to notify staff.

LPA received a death report for Resident 3 (R3). According to the administrator, R3 was on hospice and died of natural causes.

Per California Code of Regulations (CCR) - Title 22 - no deficiencies were observed. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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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