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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700801
Report Date: 07/07/2021
Date Signed: 07/07/2021 03:11:20 PM

Document Has Been Signed on 07/07/2021 03:11 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:MINNESOTA HOME CAREFACILITY NUMBER:
342700801
ADMINISTRATOR:OKVERE, VERA A.FACILITY TYPE:
740
ADDRESS:7448 MINNESOTA DR.TELEPHONE:
(916) 729-9461
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 4DATE:
07/07/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Vera Okvere, LicenseeTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegation listed above. LPA met with Administrator/Licensee Vera Okyere during today's inspection. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: masks.

LPA arrived to continue investigation into complaint from the previous license. During medication review LPA observed 4 of 4 residents were missing medications when compared to physician orders. Administrator stated she does not have documentation or discontinue orders to reflect medication changes. Deficiencies are cited on 809-D.

Exit interview and appeal rights provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2021
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 07/07/2021 03:11 PM - It Cannot Be Edited


Created By: Bethany Mirlohi On 07/07/2021 at 11:49 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: MINNESOTA HOME CARE
FACILITY NUMBER: 342700801

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2021
Section Cited
CCR
87465(a)(5)

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87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed.
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Administrator agrees to obtain current physician orders and medications prescribed. Administrator to send into CCL a plan of how staff will manage residents medications and
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This requirement is not met as evidenced by: Based on observation and record review the licensee did not assists residents with medications as prescribed which poses an immediate health and safety risk to residents in care.
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 obtain physician documentation. POC due by 7/8/21.

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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:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021


LIC809 (FAS) - (06/04)
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