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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700338
Report Date: 11/15/2021
Date Signed: 11/15/2021 04:02:33 PM

Document Has Been Signed on 11/15/2021 04:02 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:SIGNATURE LIVING ON STORY RIDGE WAYFACILITY NUMBER:
342700338
ADMINISTRATOR:RIMANDO, NORAFACILITY TYPE:
740
ADDRESS:8400 STORY RIDGE WAYTELEPHONE:
(916) 300-5363
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 6DATE:
11/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Nerry Rimando-Afable, AdministratorTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analysts (LPA) Michael Hood arrived at the facility and met with Administrator, Nerry Rimando-Afable, to follow-up regarding information received from a previous interview conducted. Facility currently does not have any COVID-19 positive cases. LPA wore N-95 mask and was screened by facility upon entry. Facility staff wore masks in the care home.

During previous interviews conducted with relevant parties, it was discovered that staff may have not reported incident to Community Care Licensing. LPA conducted interview with staff member (S1), Administrator, and received contact information for former resident (R1).

At this time, further investigation is needed regarding information above.

During previous interviews conducted, it was discovered that staff may be sleeping at the facility when there is not a designated staff member bedroom. LPA observed garage with bed and dresser. Administrator stated that staff had previously slept in garage but were instructed that they may no longer use the garage as a bedroom and must move their belongings. LPA observed facility sketch and found that garage was listed as "storage" and not approved as a designated staff member bedroom for staff to sleep in.

Due to interviews previously conducted, documents reviewed, and LPA's observation, per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 809-D page due to staff sleeping at the facility when facility does not have an approved staff member bedroom.

Exit interview was conducted with Administrator and a copy of this report and appeal rights were provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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 11/15/2021 04:02 PM - It Cannot Be Edited


Created By: Michael Hood On 11/15/2021 at 03:38 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SIGNATURE LIVING ON STORY RIDGE WAY
FACILITY NUMBER: 342700338

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/24/2021
Section Cited
CCR
87307(a)

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87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by:
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Administrator will complete a statement of understanding indicating that staff will no longer sleep in the garage. Administrator will submit statement of understanding and staff will remove belongings from garage by POC due date.
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Based on interviews conducted and observations, facility did not ensure that staff were not sleeping in the facility's garage, which is indicated as a "storage" on the facility's sketch, which poses a potential health, safety, and personal rights risk to residents in care.
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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:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021


LIC809 (FAS) - (06/04)
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