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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002960
Report Date: 11/21/2023
Date Signed: 11/22/2023 08:12:53 AM

Document Has Been Signed on 11/22/2023 08:12 AM - 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:JOY'S CARE HOME-ELMFACILITY NUMBER:
315002960
ADMINISTRATOR:SUSBILLA, GLORIA JOYCE BROFACILITY TYPE:
740
ADDRESS:256 ELM STREETTELEPHONE:
(916) 297-5675
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 3DATE:
11/21/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:CaregiverTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 11/21/23 to conduct a Post Licensing Inspection utilizing the CARE inspection tool. LPA met with a caregiver and explained the purpose of the visit. Licensee and Admin arrived for review.

LPA and caregiver toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, 1 resident bedroom, kitchen and dining. In the areas toured no immediate health, safety, or personal rights violations were observed.
R1's room needs the exit door to be cleared of furniture or R1 agrees to move to a different room.

LPA reviewed resident files. R3 needs an updated LIC 602 and Services Plan. R1 needs an order to use a recliner vs a bed and licensee to submit an exception request.
Staff files were reviewed. 3 of 3 staff do not have required training on file.

LPA requested resident roster and LIC 500 be submitted and liability insurance certificate (certificate to be submitted by 11/27/23).

As a result of this inspection, 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.
Exit interview conducted. Report copy and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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 3
Document Has Been Signed on 11/22/2023 08:12 AM - It Cannot Be Edited


Created By: Kevin Mknelly On 11/21/2023 at 03:41 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: JOY'S CARE HOME-ELM
FACILITY NUMBER: 315002960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 3 of 3 staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2023
Plan of Correction
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Licensee will submit proof of required training to CCL by the POC date of 11/29/23
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review the licensee did not comply with the section cited above in 3 of 3 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2023
Plan of Correction
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Licensee will submit proof of required training as well as a LIC 500 to CCL by the POC date of 11/29/23.
In oder to establish a trained staff is on site at all times.
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: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/22/2023 08:12 AM - It Cannot Be Edited


Created By: Kevin Mknelly On 11/21/2023 at 03:41 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: JOY'S CARE HOME-ELM
FACILITY NUMBER: 315002960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review the licensee did not comply with the section cited above in out of 1 of 3 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2023
Plan of Correction
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Licensee will submit copies of physican report and Needs and Services blan by the POC date of 12/12/23.
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:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
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