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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700585
Report Date: 12/30/2022
Date Signed: 12/30/2022 09:53:56 AM

Document Has Been Signed on 12/30/2022 09:53 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, 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: DATE:
12/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Paul and Teresita Almondehe, LicenseesTIME COMPLETED:
10:30 AM
NARRATIVE
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On 12/30/22, License Programming Analyst (LPA) Renee Campbell conducted a Case Management visit to issue a citation for findings discovered during a complaint investigation COMPLAINT CONTROL NUMBER: 27-AS-20220909152751. LPA was met by Paul and Teresita Almondehe and explained the purpose of the visit.

During the course of the investigation into the above listed complaint number the LPA conducted interviews with staff and clients, in addition the resident file was reviewed. A preplacement appraisal was completed 01/09/2020, interviews revealed that the resident began to wander during the first week of placement, a reappraisal was not completed as required to address the safety concerns until 10/01/2021.

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: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2022
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 12/30/2022 09:53 AM - It Cannot Be Edited


Created By: Renee Campbell On 12/30/2022 at 09:04 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: INDOCARE HOUSE 2
FACILITY NUMBER: 342700585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2023
Section Cited
CCR
87463(a)

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97463(a) The pre-admission appraisal shall be updated,.. to keep the appraisal accurate......when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first.. This requirement was not met as evidenced by:
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Administrator will audit all resident charts to ensure appraisals are accurate and up to date and they will then read the regulation regarding this citation and write a statement confirming same by POC due date. Both items will be emailed to renee.campbell@dss.ca.gov
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Based on interviews and record reviews, the licensee did not update the appraisal when the resident began to wander during the first week of placement.
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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:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2022


LIC809 (FAS) - (06/04)
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