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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700785
Report Date: 12/14/2023
Date Signed: 12/14/2023 12:14:11 PM

Document Has Been Signed on 12/14/2023 12:14 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:7125 MAIN, LLCFACILITY NUMBER:
342700785
ADMINISTRATOR:GLADYS GASTAFACILITY TYPE:
740
ADDRESS:7125 MAIN AVETELEPHONE:
(707) 592-4004
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6CENSUS: 6DATE:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Facility staff- Julene AndersonTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains arrived on 12/14/23 to conduct the annual inspection. LPA met with Facility staff- Julene Anderson (S1) and explained the purpose of today's visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (2) and staff files (2). All residents files have required paperwork. LPA observed incomplete paperwork (LIC503 and TB) for staff (S1,S2) files as mentioned in 809D.

LPA and S1 toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Hot water temperature was observed to be 120 degrees F, which is within the regulation range of 105-120 degree. Fire extinguisher was ready for emergency use.

LPA audit centrally store log for medications for residents (R1,R2). R2 medication log was found to be accurate. For R1 medication log audit, LPA observed that prescription medications were not matching the dosage, refill dates with original bottle/container and also found 4 PRN medications with expired dates for R1.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 12/31/23 . Deficiencies are cited on LIC809D per Title 22. Exit interview conducted. Appeal Rights and copy of this report left at facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 12/14/2023 12:14 PM - It Cannot Be Edited


Created By: Talwinder Bains On 12/14/2023 at 11:48 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: 7125 MAIN, LLC
FACILITY NUMBER: 342700785

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review for centrally stored medication log , LPA observed that prescription medications were not matching the dosage, refill dates with original bottle/container and also found 4 PRN medications with expired dates for R1, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Licensee/administrator will send letter of understanding of regulation 87465(a) and will do staff training as well and will send proof to department by POC date,12/15/23. Additionaly, facility will ensure to keep proper centrally stored log for R1 and for other residents for all medications. Facility shall do monthly staff training for medication administration till Feb.2024 and send training documents to LPA
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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/14/2023 12:14 PM - It Cannot Be Edited


Created By: Talwinder Bains On 12/14/2023 at 11:48 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: 7125 MAIN, LLC
FACILITY NUMBER: 342700785

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed that staff files for S1,S2 were missing LIC503 (Health Screening ) and TB test as required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Licensee/administrator shall complete all required documents for all staff files including S1,S2 for LIC503 (Health Screening ) and TB test and will send proof to department by POC date, 12/28/23.
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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4