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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 030317773
Report Date: 08/26/2024
Date Signed: 08/26/2024 02:15:11 PM

Document Has Been Signed on 08/26/2024 02:15 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AMADOR RESIDENTIAL CARE FACILITYFACILITY NUMBER:
030317773
ADMINISTRATOR/
DIRECTOR:		KARLY STURGEONFACILITY TYPE:
740
ADDRESS:155 PLACER DRIVETELEPHONE:
(209) 223-4444
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY: 49CENSUS: 26DATE:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Karly SturgeonTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 8/26/24, at 10:50am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to the facility unannounced to conduct an annual required visit. LPA met with Karly Sturgeon, Administrator (ADM), and explained the purpose of the visit. During this visit, present were 26 residents in care, in Assisted Living (AL) and Memory Care (MC) and 10 total staff on duty.

The facility, a single-story building with a capacity for up to 49 residents, is situated in a residential neighborhood. LPA and ADM conducted a physical inspection of the facility to ensure compliance with Title 22 regulations.

During the inspection, LPA examined 2 AL and 2 MC resident bedrooms. Each room was furnished with essential items: a bed, chair, lamp, dresser, and closet space. Emergency exits were unobstructed. Resident bathrooms were found to be clean and well-equipped. Medications, sharps, and cleaning supplies were securely locked away from residents. Common areas were tidy and free from obstructions. Fences and gates were in good repair, with delayed egress and secure gates in the MC area. There were no fireplaces or bodies of water present. The hot water temperature in one resident's bedroom was recorded at 115°F, and the room temperature was 68°F. Carbon monoxide and smoke detectors, pull alarms, and a sprinkler system were all present and functioning. The kitchen was inspected, and food supplies were appropriately stored. The facility maintains a 2-day supply of perishable and a 7-day supply of nonperishable food. With 3 freezers and 2 refrigerators, all were found to be operating within regulatory temperature ranges. Currently, no residents are using oxygen.

LPA reviewed 5 staff files, all of which were in compliance. Among 6 resident files reviewed, it was noted that 2 residents had become bedridden. The facility do not have evidence of fire clearance documentation for bedridden residents during this visit. Through interview and record review, facility has notified local fire department when these residents became bedridden status. Medication records for 2 of the 6 residents were found to be compliant. The facility conducts quarterly fire drills as part of its disaster procedure.



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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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 08/26/2024 02:15 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 08/26/2024 at 01:43 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AMADOR RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 030317773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. During resident file review, LPA discovered 2 of 6 resident has become bedridden. Through facility record review from the RO record, fire inspection record dated 7/28/23 does not show facility was granted bedridden residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2024
Plan of Correction
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Licensee and/or Administrator will submit a statment of understading of the regulation noted above as it relates to fire clearance for bedridden residents. Submit statement by POC due date.
Licensee will submit LIC 200 along with updated floor plan and request, bedridden status for residents. LPA will initiate a fire inspection request for bedridden status and Licensee will also contact Fire Department for notification two bedridden residents in facility.
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:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AMADOR RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 030317773
VISIT DATE: 08/26/2024
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LPA requested a copy of the following documents to be emailed by end of day on 8/27/24: updated LIC500, LIC308 and current Liability Insurance Certificate.

Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, deficiencies were observed. An immediate civil penalty is being assessed during today's visit. Note that failure to correct deficiencies will result in additional civil penalties.

An exit interview was held, and a copy of the report and appeal rights were provided
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024
LIC809 (FAS) - (06/04)
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