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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701001
Report Date: 03/08/2022
Date Signed: 03/08/2022 02:41:44 PM

Document Has Been Signed on 03/08/2022 02:41 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:A1 SENIOR CARE 2FACILITY NUMBER:
312701001
ADMINISTRATOR:TACANDONG, DAISYREEFACILITY TYPE:
740
ADDRESS:2040 SYMPHONY AVETELEPHONE:
(916) 472-4543
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 6DATE:
03/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Ezra Ternate, Caregiver and Jocelyn Javelana, CaregiverTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kerry Hiratsuka and Lavinia Muscan arrived at the facility unannounced on 03/08/2022 to conduct a case management visit during a complaint visit. LPAs conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPAs were screened by Caregiver.

It was discovered during today's visit the caregivers are giving insulin injections to a resident at the resident's request. The caregivers are not licensed skilled medical professionals and they are not allowed to give injections per Title 22 regulations.

Deficiency is cited on 809-D, per Title 22 Regulations, Division 6. Appeal rights were provided to the caregiver on duty.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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 03/08/2022 02:41 PM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 03/08/2022 at 02:12 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: A1 SENIOR CARE 2
FACILITY NUMBER: 312701001

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2022
Section Cited
CCR
87628(a)

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Diabetes. The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection,
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By 03/09/2022, the licensee shall submit in writing how she is going to ensure either a resident who requires injections does it by themselves or have a licensed skilled medical professional do it.
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or has it administered by an appropriately skilled professional.
This requirement was not met as evidenced by: the caregivers, who are not licensed skilled medical professionals are giving insulin injects at the resident's request. This is an immediate safety risk to residents.
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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:Troy Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022


LIC809 (FAS) - (06/04)
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