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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052700992
Report Date: 09/19/2024
Date Signed: 09/19/2024 12:47:39 PM

Document Has Been Signed on 09/19/2024 12:47 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:		JACOB HARRYMANFACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY: 78CENSUS: 51DATE:
09/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Jacob Harryman and Angelica WhiteTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 9/19/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management in relation to an incident report that was received. LPA Jensen met with Executive Director Jacob Harryman and Memory Care Director Angelica White.

LPA Jensen received an incident report wherein an assisted living resident (R1) reported vomiting black blood. LPA Jensen reviewed R1's Physician's Report (LIC 602), Pre-Admission Appraisal, Medication Administration Record (MAR), Needs and Service Plan, Progress Notes and incidents reports from 2024. LPA Jensen observed an LIC 602 that indicates R1 requires a mechanical soft diet. LPA Jensen also observed that the Needs and Service Plan did not indicate any kind of special diet requirements. As a result of record reviews and interviews conducted with the Executive Director and Memory Care Director it was learned that R1's LIC 602 was completed when R1 left a skilled nursing facility and mechanical soft diet was no longer required after he returned to the facility. A physcian's order for regular diet is now on file. It was also learned that the incident reported was unrelated to R1's dietary needs.

LPA Jensen provided technical assistance and recommended that all LIC 602's are checked for accuracy, updated as needed and that facility staff should ensure that Needs and Service Plans reflect the physician report indicators.

No citations were issued as a result of this visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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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