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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700029
Report Date: 10/04/2022
Date Signed: 10/04/2022 12:08:42 PM

Document Has Been Signed on 10/04/2022 12:08 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CALI CARE RETIREMENT HOMEFACILITY NUMBER:
342700029
ADMINISTRATOR:MOJICA, CYNTHIAFACILITY TYPE:
740
ADDRESS:3630 WEST WAYTELEPHONE:
(916) 484-3027
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: 4DATE:
10/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Emmanuel A Mojica TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 10/04/2022. LPA met with Emmanuel A Mjica and explained the purpose of the visit.

The purpose of today's visit is in response to learned deficiencies. It was learned the facility did not conduct a reappraisal, after resident 1 (R1) had a change in health condition. In addition LPA Martinez reviewed R1's facility file, and there was not an admission agreement in R1's file. LPA Martinez requested R1's admission agreement during a visit, and the facility staff was not able to find or provide the admission agreement. As a result, deficiencies were cited per California Code of Regulations, Title 22, and California Health and Safety Code, and the citations can be found on the 809 D page.

An exit was conducted interview, and a copy of this report and appeal rights given were given to the facility

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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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Document Has Been Signed on 10/04/2022 12:08 PM - It Cannot Be Edited


Created By: Avelina Martinez On 10/04/2022 at 11:34 AM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CALI CARE RETIREMENT HOME
FACILITY NUMBER: 342700029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2022
Section Cited
CCR
87463(a)(3)

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87463(a)(3) Reappraisals: the pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes...reappraisals shall document changes in the resident's physical, medical, mental, and social condition...Any illness, injury, trauma, or change in the health care needs
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Administrator agrees to conduct a reappraisal and review change of health condition with Alta Regional Center. Administrator agrees to contact R1's Physician to report R1's change in condition. Administrator will email LPA Martinez reassessment by 10/05/2022.
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This requirement was not met as evidence by: Based on observation, interviews and record review, the facility did not conduct a reappraisal after R1 developed a pressure injury. This posed an immediate health and safety risk to R1.
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Type B
10/18/2022
Section Cited
CCR87507(a)

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Admission Agreement (a) The licensee shall complete an individual written admissions agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.
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Administrator agrees to complete an admission agreement for R1 by POC 10/18/2022. The administrator agrees to email the admission agreement LPA Martinez by POC Date 10/18/2022.
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This requirement was not met as evidence by: Based on observation, interviews and record review, the facility did not ensure R1 had a completed admission agreement in their file. This posed a potential health and safety risk to R1.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022


LIC809 (FAS) - (06/04)
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