Community Care Licensing

Document Has Been Signed on 09/26/2024 03:18 PM - It Cannot Be Edited

FACILITY NAME:	CHERRY RIDGE VILLA		FACILITY NUMBER:	315920021
ADMINISTRATOR/ DIRECTOR:	KAUR, NIRMALJEET		FACILITY TYPE:	740
ADDRESS:	6893 CHERRY RIDGE CIR.		TELEPHONE:	(916) 786-0654
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95678
CAPACITY: 6		CENSUS: 6	DATE:	09/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	caregiver		TIME VISIT/ INSPECTION COMPLETED:	06:00 PM

SUPERVISORS NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024

Link to Parent Document Below:

FACILITY NAME: CHERRY RIDGE VILLA	FACILITY NUMBER: 315920021
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2024

Type B

Section Cited

CCR

87303(d)

(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. 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 S3 is a live in staff residing a room not designed for staff occupency which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Licensee will establish appropriate accomodations for staff or have not have staff live in by the POC date of 10/10/24. be cleared by visit.

Type B

Section Cited

HSC

1569.625(b)(2)

(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
1 2 3 4	Based on records review the licensee did not comply with the section cited above in S2 did not have required training prior ro working with residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/03/2024
	Plan of Correction
1 2 3 4	R2 staff is to be completed and supervised until completed. Proof of training to be submitted by 10/3/24.

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024

Link to Parent Document Below:

FACILITY NAME: CHERRY RIDGE VILLA	FACILITY NUMBER: 315920021
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2024

Type B

Section Cited

HSC

1569.625(d)(1)

(1) A licensed or certified health professional with valid certification shall receive eight hours of training on resident characteristics, resident records, and facility practices and procedures prior to providing direct care to residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review the licensee did not comply with the section cited above in [count] out of 1 of 3 , S1 , staff files reviewed found insufficient training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/17/2024
	Plan of Correction
1 2 3 4	Licensee to submit proof of completed staff traing for S1 by the POC date of 10/17/24

Type B

Section Cited

CCR

87458(a)

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based onresident records, the licensee did not comply with the section cited above in 2 of 6 residents, R1 and R3, have dementia diagnosis with assessments greater that 12 months old which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2024
	Plan of Correction
1 2 3 4	Licensee will submit up to date LIC 602s for R1 and R3 by 10/24/24

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024

Link to Parent Document Below:

FACILITY NAME: CHERRY RIDGE VILLA	FACILITY NUMBER: 315920021
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2024

Type B

Section Cited

CCR

87463(a)(3)

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 1 of 6 residents, R6, did not have a completed pre-appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2024
	Plan of Correction
1 2 3 4	Licensee will submit a plan for who will be assigned to ensure pre-appraisals are completed and LIC 625s will be submitted by 10/24/24.

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: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024

Link to Parent Document Below:

FACILITY NAME: CHERRY RIDGE VILLA	FACILITY NUMBER: 315920021
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2024

Type A

Section Cited

CCR

87203

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 the smoke detector in the living room was non-operational for approximately several days without repair which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2024
	Plan of Correction
1 2 3 4	Licesee contacted the fire department who will inspect and advise repair. Licensee will submit the recommended plan to correct by 9/27/24. proof of completion will be submitted when done as recommended.

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: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024