315002812-10-30-2024-59-AS-KHIA-DAJUYS-20241030160025

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 315002812
Report Date: 10/30/2024
Date Signed: 10/30/2024 04:00:32 PM

Document Has Been Signed on 10/30/2024 04:00 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:	BLESSED HOMECARE 2 ROSEVILLE		FACILITY NUMBER:	315002812
ADMINISTRATOR/ DIRECTOR:	ARGANA, FERDINAND		FACILITY TYPE:	740
ADDRESS:	4100 SHORTHORN WAY		TELEPHONE:	(209) 834-4040
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY: 6		CENSUS: 6	DATE:	10/30/2024
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:15 PM
MET WITH:	Baby O Quintero		TIME VISIT/ INSPECTION COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Hiratsuka and Mikkelson conducted this unannounced plan of correction visit in response to deficiencies cited for Complaint 59-AS-20241022104408 and a Case Management visit on 10/24/2024. LPA Mirlohi arrived later to conduct her own Plan of Correction visit. On 10/24/2024, the following deficiencies were issued and they are not corrected as of today: -Health and Safety Code 1569.312(e) Basic Services- this was cited because a resident made it out of the facility unnoticed by staff and was found about four blocks away. The Licensee was to submit a written plan of correction on how she shall ensure how staff monitor residents based on needs. Licensee did not submit this plan. Civil penalties of $500.00, is issued today and shall accrue at $100.00 until Licensee submits contacts LPA Hiratsuka. -Title 22 Regulation 87465(e) Incidental Medical and Dental Care. this was cited because per Title 22 the facility shall telephone 9-1-1 if there is an imminent threat to the health and safety to residents. A resident left the facility unnoticed and Licensee took approximately 30 minutes before calling 9-1-1. Licensee was to submit a written plan that addresses what staff are going to do when a resident is missing. Civil penalties of $500.00, is issued today and shall accrue at $100.00 until Licensee submits contacts LPA Hiratsuka. -87307(d)(6) Personal Accommodations and Services. This was cited because the front door was blocked by two chairs and the sliding glass door had a wood rod put on the track to keep the door from sliding open. The chairs and wood rod were removed, but the licensee did not submit a written plan of correction on how she is going to ensure the exits are not blocked. Civil penalties of $500.00, is issued today and shall accrue at $100.00 until Licensee submits contacts LPA Hiratsuka.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLESSED HOMECARE 2 ROSEVILLE	FACILITY NUMBER: 315002812
	VISIT DATE: 10/30/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

-87463(a) Reappraisals. This was cited because the appraisal and needs and services plan for the residents did not meet what the residents needs were. One did not mention the resident was a wanderer and there was a second one that had a resident's name written over White-Out, and had another person's name in the body of it. Licensee was to submit a written plan how she was going to ensure the appraisals and needs and services plan address the resident abilities and needs and how she was going to have the staff meet those needs. Civil penalties of $500.00, is issued today and shall accrue at $100.00 until Licensee submits contacts LPA Hiratsuka.

The following was not corrected but no civil penalties issued because the licensee did part of the plan of correction:
-87705(j) Care of Persons with Dementia. Title 22 regulations requires audio alerts on exits when exiting poses a risk to residents. Licensee blocked the front door with two chairs and put a wood rod on the track of the sliding glass door. The licensee has removed the chairs and the wood rod. Licensee installed audio alerts on the exits. Licensee was to submit a written plan of correction of how she shall ensure the exits are not blocked and the audio alerts working. LPA is not issuing civil penalties and Licensee is to submit a written plan about the audio alerts and not blocking exits.

A total of $2000.00 civil penalties were issued. The four uncorrected deficiencies shall accrue at $100.00 per day until Licensee submits a written plan of correction.

No additional deficiencies issued during this visit.

Appeal rights left for the civil penalties. A copy of the report has been issued

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2