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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700458
Report Date: 11/16/2022
Date Signed: 11/16/2022 04:35:18 PM

Document Has Been Signed on 11/16/2022 04:35 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:MUIRFIELD A HOME FOR THE ELDERLYFACILITY NUMBER:
342700458
ADMINISTRATOR:CARPIO, ORLANDOFACILITY TYPE:
740
ADDRESS:7541 MUIRFIELD WAYTELEPHONE:
(916) 424-4553
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 6CENSUS: 6DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Marilyn CarpioTIME COMPLETED:
04:45 PM
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On 11/16/22 at 2:55 pm, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection. Upon LPAs arrival, House Manager Marilyn Carpio was present at facility and notified Administrator Orlando Carpio Jr. that LPA is presence at the facility. LPA was advised that Marilyn Carpio will be able to assist with today’s inspection.

Administrator holds current certification #6024159740 and expires on 11/8/2022. The facility is licensed to serve six (6) non-ambulatory residents. Hospice waiver approved for 4 residents. There are currently six (6) residents who reside at this facility of which 1 resident is on hospice. LPA toured the facility with Marilyn Carpio on 11/16/2022 at 3:10 pm.

LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. Hot water temperature was observed to be 113.5 degrees Fahrenheit. Facility thermostat observed at 74 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable.

LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA also conducted the infection control domain tool.

Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MUIRFIELD A HOME FOR THE ELDERLY
FACILITY NUMBER: 342700458
VISIT DATE: 11/16/2022
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The facility mitigation plan was submitted to CCLD, and it was approved on 2/16/2021. Facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

Administrator was informed to send updated copies of the following documents to CCL within 15 days:

(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

The following deficiencies are cited per California Code of Regulations, TITLE 22.

Exit interview was conducted, a copy of this report and Appeal Rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
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Document Has Been Signed on 11/16/2022 04:35 PM - It Cannot Be Edited


Created By: Tung Truong On 11/16/2022 at 04:20 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MUIRFIELD A HOME FOR THE ELDERLY
FACILITY NUMBER: 342700458

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(a)
87405(a) Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and records review, the licensee did not ensure the facility has an active certified Administrator. Administrator Orlando Carpio’s administrator certificate expired 11/8/2022. This poses an immediate health and safety risk to residents in care.
POC Due Date: 11/17/2022
Plan of Correction
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Licensee shall ensure that a certified administrator is designated and submit documentation for approving a new certified administrator to the department by the POC due date.
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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Tung Truong
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022


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