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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002973
Report Date: 11/01/2024
Date Signed: 11/01/2024 04:04:44 PM

Document Has Been Signed on 11/01/2024 04:04 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:MORGAN CREEK VILLAFACILITY NUMBER:
315002973
ADMINISTRATOR/
DIRECTOR:		KING, ROBERTFACILITY TYPE:
740
ADDRESS:9565 PINEHURST DRIVETELEPHONE:
(916) 846-3169
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 6DATE:
11/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Rodel Besana and Maricar KingTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cassandra Mikkelson and Michael Hood arrived unannounced to conduct an annual inspection. LPAs met with assistant manager Rodel Besana and Administrator Maricar King during today's inspection.

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPAs observed five (5) resident rooms, one (1) staff room, one (1) staff bathroom and two(2) common area bathrooms. LPAs observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 115.9 degrees F.

LPAs checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are hard wired and operational in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPAs checked medication storage and found medications to be locked away and inaccessible to the residents. LPAs reviewed six (6) resident files and three (3) staff files. Facility has a current copy of certificate of liability insurance and LPAs obtained a copy.

As a result of this visit, deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. An immediate civil penalty in the amount of $500 was assessed per Health and Safety Code 1548 for a violation regarding fire clearance. Deficiencies are listed on 809-D pages.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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 12
Document Has Been Signed on 11/01/2024 04:04 PM - It Cannot Be Edited


Created By: Cassandra Mikkelson On 11/01/2024 at 02:59 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: MORGAN CREEK VILLA
FACILITY NUMBER: 315002973

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and records reviewed, facility did not ensure that they had a fire clearance for bedridden persons before retraining a resident who was considered bedridden according to their LIC 602A, which poses an immediate health,safety and personal rights risk to the resident in care.
POC Due Date: 11/02/2024
Plan of Correction
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Facility will apply for an exception for bedridden resident by POC due date. An immediate civil penalty in the amount of $500.00 was assessed for today's date for a violation that the Department determines violated the facility's fire clearance.
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:Anthony Perez
LICENSING EVALUATOR NAME:Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
Page: 2 of 12
Document Has Been Signed on 11/01/2024 04:04 PM - It Cannot Be Edited


Created By: Cassandra Mikkelson On 11/01/2024 at 02:59 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: MORGAN CREEK VILLA
FACILITY NUMBER: 315002973

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and records reviewed, the facility did not ensure all staff files are complete and current during inspection, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2024
Plan of Correction
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Facility will ensure that all personnel records are complete and current at the facility at all times. Facility will complete a statement of understanding regarding the regulation by POC due date.
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and review of records, the facility did not ensure that staff handling medications had medication training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2024
Plan of Correction
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Facility will conduct an inservice training regarding medications and submit certificate to LPA. Facility will ensure that medication trainings are done annually.
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:Anthony Perez
LICENSING EVALUATOR NAME:Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 11/01/2024 04:04 PM - It Cannot Be Edited


Created By: Cassandra Mikkelson On 11/01/2024 at 02:59 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: MORGAN CREEK VILLA
FACILITY NUMBER: 315002973

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(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
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Based on LPAs observation and review of records, the facility did not ensure drill logs were documented properly according to health and safety code which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2024
Plan of Correction
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Facility will document drills in accordance with Health and Safety code and ensure that documentation is maintained at the facility at all times.
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:Anthony Perez
LICENSING EVALUATOR NAME:Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
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