Community Care Licensing

Document Has Been Signed on 08/28/2023 04:01 PM - It Cannot Be Edited

FACILITY NAME:	LINCOLN RESIDENCE 1408		FACILITY NUMBER:	315002194
ADMINISTRATOR:	GRACE HAWKINS		FACILITY TYPE:	740
ADDRESS:	1408 ALDER CREEK COURT		TELEPHONE:	(916) 543-1338
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY: 6		CENSUS: 6	DATE:	08/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Grace Hawkins		TIME COMPLETED:	04:15 PM

SUPERVISORS NAME: Maribeth Senty LICENSING EVALUATOR NAME: Melissa Parks LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023

Link to Parent Document Below:

FACILITY NAME: LINCOLN RESIDENCE 1408	FACILITY NUMBER: 315002194
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2023

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 2 bathroom water temperatures which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2023
	Plan of Correction
1 2 3 4	Administrator to send a statement of understanind by end of day 8/29/2023. Administrator to take water temperatures twice a day, for 7 days, and send record to LPA.

Type A

Section Cited

CCR

87307(a)(2)(B)

(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by allowing staff to live in hallway closet which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2023
	Plan of Correction
1 2 3 4	Administrator to send LPA pictures of closet empty of staff personal belongings.

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Melissa Parks LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023

Link to Parent Document Below:

FACILITY NAME: LINCOLN RESIDENCE 1408	FACILITY NUMBER: 315002194
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2023

Type B

Section Cited

HSC

1569.618(c)(3)

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff records reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2023
	Plan of Correction
1 2 3 4	Administrator to email LPA copies of staff current first aid/cpr training

Type B

Section Cited

CCR

87458(b)(1)

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out 6 clients not having TB records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Administrator to submit copies of missing TB records for 5 residents

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Melissa Parks LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023

Link to Parent Document Below:

FACILITY NAME: LINCOLN RESIDENCE 1408	FACILITY NUMBER: 315002194
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2023

Type B

Section Cited

HSC

1569.695(c)

(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
1 2 3 4	Based on record review the licensee did not comply with the section cited above by not having any fire drills within the past two years which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2023
	Plan of Correction
1 2 3 4	Administrator to submit statement of understaning regarding regulation. Administrator to submit record of one fire drill.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Melissa Parks LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023