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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 115002791
Report Date: 04/11/2024
Date Signed: 04/11/2024 02:09:18 PM

Document Has Been Signed on 04/11/2024 02:09 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:RIVERSIDE COUNTRY HOMEFACILITY NUMBER:
115002791
ADMINISTRATOR/
DIRECTOR:		LOEWEN, ROLANDFACILITY TYPE:
740
ADDRESS:8096 HIGHWAY 162TELEPHONE:
(530) 934-3686
CITY:GLENNSTATE: CAZIP CODE:
95943
CAPACITY: 6CENSUS: DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Board Member- Geoffrey GiesbrechtTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 04/11/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with a Bored Member Geoffrey Giesbrecht, and explained the purpose of the visit.

LPA Boyles and Facility Board Member toured facility together to ensure health and safety of residents in care. LPA observed the facility to be clean, in good repair and odor-free.

Areas toured include but are not limited to: common areas, resident bedrooms, backyard and common restrooms. LPA observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster. LPA observed each bedroom to have the required furnishings, windows with screens and working lights. LPA observed a plethora of activities for the residents. Facility has a 2-day perishable and a 7-day non-perishable amount of food. Hot water temperature was measured at 118 F. LPA observed two (2) fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed the first aid kit to be complete and ready for emergency use.

LPA observed chemicals to be unlocked and accessible to residents in care in two locations: Kitchen under the sink and the laundry room cabinet. LPA observed medications to be locked and inaccessible to residents in care. LPA observed a completed emergency disaster plan but no documentation that emergency drills occurred within the last 12 months. LPA observed a resident to have half bed rails with no orders from a doctor for the utilization of the bed rails.

LPA reviewed a total of five (5) residents' files and three (3) staff files which contained all of the required documentation.

Several topics were discussed.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.



An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A
copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 04/11/2024 02:09 PM - It Cannot Be Edited


Created By: Jaynae Boyles On 04/11/2024 at 01:32 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: RIVERSIDE COUNTRY HOME
FACILITY NUMBER: 115002791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in that chemicals were unlocked and accessible to residents in two locations (Kitchen/Laundry Room) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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Licensee will develop a plan to ensure that all chemicals are locked and inaccessable to residents. Licensee will train all staff of the importance of ensuring that all chemicals are locked an inaccessible to residents. Licensee will check the locks monthly to ensure they are in working order.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/11/2024 02:09 PM - It Cannot Be Edited


Created By: Jaynae Boyles On 04/11/2024 at 01:32 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: RIVERSIDE COUNTRY HOME
FACILITY NUMBER: 115002791

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation record review, the licensee did not comply with the section cited above in that no emergency disaster drills have been documented within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
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Licensee will ensure that emergency disaster drills are conducted four times a year and document the emergency disaster drills. Licensee will develop a plan to ensure these disaster drills are completed and share that plan with the LPA within one week.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in one out of one resident has half bed rails without an order from a doctor which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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Licensee will ensure that the resident who has bed rails will obtain a doctors order. Licensee will ensure that residents who have bed rails who are not on hospice have an order from their doctor indicating the need for bed rails.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


LIC809 (FAS) - (06/04)
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