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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700585
Report Date: 05/17/2021
Date Signed: 05/17/2021 02:14:27 PM

Document Has Been Signed on 05/17/2021 02:14 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:INDOCARE HOUSE 2FACILITY NUMBER:
342700585
ADMINISTRATOR:LOMENDEHE, PAULFACILITY TYPE:
740
ADDRESS:8604 BANFF VISTA DRTELEPHONE:
(916) 686-1253
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
05/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Orpha ManglansanTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Ashley Boothe and Tirzah Hubbard conducted an unannounced visit to on 5/17/2021 at 1:00pm. LPA's met with Staff one (S1) and identified the purpose of the visit. LPA Boothe conducted facility COVID assessment with Administrator prior to today's visit via telephone call at 11:59am. LPA Boothe contacted Administrator who stated they were unable to come to the facility and designated S1. LPA's were allowed entry to the facility. Three of three staff observed cleared in Licensing Information System. Current census 6 and 0 Hospice residents.

At 1:00pm LPA's observed S1 not wearing a mask while working in the facility and did not screen LPA's for COVID precautionary measures. S1 put on a mask upon LPA's request. At 1:15pm LPA's observed Staff two (S2) and Staff three (S3) not wearing a mask while working in the facility. S2 and S3 put on a mask upon LPA's request. S1, S2, and S3 stated they had just finished lunch and forgot to put it back on but wear them. S1 screened LPA's temperature LPA's signed visitor log during the visit upon LPA's request.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2021
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 05/17/2021 02:14 PM - It Cannot Be Edited


Created By: Ashley Boothe On 05/17/2021 at 01:32 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: INDOCARE HOUSE 2
FACILITY NUMBER: 342700585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2021
Section Cited
CCR
87468.1(a)(2)

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Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidence by:
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S1, S2, and S3 put on a mask and screened LPA's for COVID precautionary measures. The licensee agrees to submit a written declaration to maintain compliance with this regulation at all times to LPA by POC due date of 5/18/2021.
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Based on observation and interview the licensee did not protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that S1, S2, and S3 did not wear face coverings while providing care and supervision to clients in care, in violation of official government orders requiring the wearing of face coverings while working under specified conditions which poses an immediate health and safety 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:Liza King
LICENSING EVALUATOR NAME:Ashley Boothe
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2021


LIC809 (FAS) - (06/04)
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