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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052700992
Report Date: 05/16/2024
Date Signed: 05/16/2024 04:36:50 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/16/2024 04:36 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:FOOTHILL VILLAGE SENIOR LIVINGFACILITY NUMBER:
052700992
ADMINISTRATOR/
DIRECTOR:		MARY MCCLUREFACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY: 78CENSUS: 67DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Mary McClureTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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THIS IS A CONTINUATION OF THE REQUIRED 1 YEAR ANNUAL COMMENCED ON 5/15/24

On 5/16/24 Licensing Program Analyst Maja Jensen arrived at facility unannounced to continue a required 1 year annual inspection. LPA Jensen met with Executive Director Mary McClure and explained the purpose of today's visit.

On 5/15/24 LPA Jensen toured the grounds and physical plant. All paths on the grounds were observed to be free of obstruction. There are shaded areas and patio furniture for the residents to enjoy outdoor activities. There are no bodies of water on the property. LPA Jensen observed a broken hand rail on an exterior patio that was marked with caution tape. LPA Jensen confirmed with the Maintenance Director and the Executive Director that the rail has been broken for approximately one week and repairs are currently in process. LPA Jensen also reviewed documentation confirming a contractor is scheduled for repairs as of 5/17/24.

LPA Jensen toured the physical plant. The facility was observed to have adequate furnishings and lighting. There are night lights available in the hallways. The facility maintains an adequate supply of linens. All medications and toxins are inaccessible to residents in care. The first aid supplies were observed to be complete. There is an evacuation chair located in the stairwell. The elevator in the main hall was determined to be in working order. The fire extinguishers were last serviced in January of 2024 and are in compliance. The carbon monoxide detectors were tested and in good working order. The facility is equipped with an interior fire sprinkler system.

LPA Jensen toured the kitchen. A two day supply of perishable food was observed and a 7 day supply of non-perishable food was observed. On 6/16/24 the lunch menu consisted of Grilled Ruben on Rye with beet salad and jello. Various snacks, desserts and fresh fruits were also available. The menu is posted in a variety of places and a menu is also printed for the individual rooms.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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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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: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992
VISIT DATE: 05/16/2024
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LPA Jensen toured the memory care section of the building while accompanied by staff 1 (S1).The facility has two designated sections for memory care. LPA Jensen pointed out to S1 that 1 of 2 memory care sections has a distinct smell and is not being kept free of incontinence odor. LPA Jensen interviewed 2 staff members that state the incontinence odor in the memory care section have been an ongoing issue. LPA Jensen interviewed the Executive Director who confirmed that the carpet in the memory care unit is scheduled to be replaced. LPA Jensen reviewed and obtained a copy of the invoice for carpet replacement in this section of the building.

All required postings were placed in easily viewable locations. LPA Jensen requested and received updated copies of the LIC 500, LIC 308 and liability insurance. LPA Jensen reviewed 5 staff files and determined them to be compliant. LPA Jensen reviewed 10 resident files and determined them to be well organized, current and compliant.

The inspection tool was used during the course of this annual inspection.

Deficiencies are being cited pursuant to the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
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Document Has Been Signed on 05/16/2024 04:36 PM - It Cannot Be Edited


Created By: Maja Jensen On 05/16/2024 at 03:59 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: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2024
Section Cited
CCR
87265(b)(3)

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Managed Incontinence
...the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by:
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The Licensee is replacing the carpet and offering new incontinence care products that help to eliminate odors. An in-service training will also be conducted by POC due date with proof of correction to be sent to Department.
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Based on LPA Jensen's ability to smell incontinence odors in the facility. This poses a potential risk to the health, safety and personal rights of 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:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
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