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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700901
Report Date: 08/15/2023
Date Signed: 08/15/2023 01:35:25 PM

Document Has Been Signed on 08/15/2023 01:35 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:A LOVING AND JOYFUL HOME RCFEFACILITY NUMBER:
312700901
ADMINISTRATOR:HEYDON, ANITAFACILITY TYPE:
740
ADDRESS:609 HERNANDEZ LANETELEPHONE:
(916) 918-2429
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 6DATE:
08/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Anita Heydon (Pratap)TIME COMPLETED:
02:00 PM
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On 8/15/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Administrator.

During the course of investigating complaint numbers 59-AS-20230727143011 and 59-AS-20230728115741, LPA found additional violations not previously alleged.

Review of medications on 8/4/23 found daily medications to be administered in a kitchen drawer which was not locked. Additionally, the medication closet contained prescription and over the counter medications of past residents and some "house supply". Four of the medications or supplements were past their expiration date.
Additionally 5 staff files were found to be missing required employee records and or proof of training. 3 of the employees are no longer working at the facility. The other two staff files are in process of correction.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed. Copy of report and appeal rights provided
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
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 2
Document Has Been Signed on 08/15/2023 01:35 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 08/15/2023 at 12:36 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: A LOVING AND JOYFUL HOME RCFE
FACILITY NUMBER: 312700901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2023
Section Cited
CCR
87465(h)(2)

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Incidental Medical and Dental Care(h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not
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 Licensee will submit a plan for locked storage of medications, auditing medications for expiration dates and destruction of medications when discontinued or resident moves out
by the POC date of 8/16/23.
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met based on observation that medications were not safely stored or disposed of when expired.
This posed an immediate risk to residents.
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Type B
09/15/2023
Section Cited
CCR87412(a)

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Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement was not met in review of 5 of 7 employee files. This posed a potential risk to residents.
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Licensee will bring all current employee files to compliance for required documents and training by the POC date of 9/15/23.

To be cleared by POC date.

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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:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023


LIC809 (FAS) - (06/04)
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