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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700762
Report Date: 06/10/2024
Date Signed: 06/11/2024 08:09:12 AM

Document Has Been Signed on 06/11/2024 08:09 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BRICKYARD RESIDENCEFACILITY NUMBER:
342700762
ADMINISTRATOR/
DIRECTOR:		VIZCARRA, RHAYMONDFACILITY TYPE:
740
ADDRESS:676 BRICKYARD DRIVETELEPHONE:
(650) 303-2522
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 5DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Aeleah McDonaldTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 6/10/24 at 12:30pm Licensing Program Analyst (LPA) Kevin Gould arrived at Brickyard Residence for the purpose of conducting a required 1 year annual inspection. LPA met with staff, Aeleah McDonald and together conducted a tour of the home.

LPA and staff evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed one window screen in need of repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 96.3 degrees F which does not meet the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA observed that the facility is still pre pouring medications and advised them on the medication guidance changes. LPA observed that two resident medical assessments are not current as they have a diagnosis of dementia and are in need of updating by resident's physician.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 9020 client roster and current administrator certificate.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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 06/11/2024 08:09 AM - It Cannot Be Edited


Created By: Kevin Gould On 06/10/2024 at 02:19 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BRICKYARD RESIDENCE
FACILITY NUMBER: 342700762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA testing of hot water supply, the licensee did not comply with the section cited above as the temperature recorded was 96.3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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Licensee adjusted the water temperature and LPA will test as a follow up.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on resident record review, the licensee did not comply with the section cited above as two residents with a diagnosis of dementia did not have an updated medical assessment in the last year which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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Licensee has agreed to ensure resident files and medical assessments are current.
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:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024


LIC809 (FAS) - (06/04)
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