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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317187
Report Date: 10/26/2022
Date Signed: 10/26/2022 10:14:20 AM

Document Has Been Signed on 10/26/2022 10:14 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:G.M. ROJO GUEST HOMEFACILITY NUMBER:
340317187
ADMINISTRATOR:ROJO, MADELYN M.FACILITY TYPE:
740
ADDRESS:5637 WHITE FIR WAYTELEPHONE:
(916) 344-8072
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY: 6CENSUS: 5DATE:
10/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Madelyn Rojo TIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 10/26/22 to conduct a case management inspection to follow up on a recent medication error at facility. LPA met with facility administrator Madelyn Rojo and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted facility and completed a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical mask. LPA was screened by facility staff upon entry.

During record review and staff interviews, it has been revealed that facility kept the proper record for centrally stored medications for all residents however there was a missing signature on MAR sheet for R1s medication after the medication has been administered. Facility will implement double signature sheet for medication administration to avoid such errors in future.

No citations issued today. Exit interview conducted with administrator. Copy of the report provided.







SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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