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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700801
Report Date: 10/11/2021
Date Signed: 10/11/2021 11:22:21 AM

Document Has Been Signed on 10/11/2021 11:22 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, 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: 6DATE:
10/11/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Beatrice Okyere, CaregiverTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jacob Williams and Bethany Mirlohi arrived unannounced to conduct a Case Management. LPA met with Caregiver Beatrice Okyere during today’s inspection. LPA attempted to contact Administrator via telephone to inform her of visit and left a voicemail. 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: N-95 Masks.

During complaint investigation LPA’s observed several additional deficiencies. On 10/5/2021, Administrator/licensee failed to 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 residents in care, in that administrator failed to wear face coverings while providing care and supervision to residents in care, in violation of official government orders requiring the wearing of face coverings while working under specified conditions.
A facility tour was conducted on 10/5/2021 and 10/7/2021. LPA observed medications were being stored in the “personal residence” side of the building, however the door to the personal residence was unlocked and medications were accessible to residents in care. In addition, on 10/7/2021 LPA observed cabinets storing medications were unlocked, and medications were accessible to residents in care. In addition, LPA looked through food supply and observed 7 day non-perishable amount of food but LPA did not observe a sufficient amount of fresh fruits and vegetables. LPA observed an insufficient amount of 2-day perishable foods as required.

CONTINUED ON LIC809-C
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2021
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 10/11/2021 11:22 AM - It Cannot Be Edited


Created By: Jacob Williams On 10/11/2021 at 08:20 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: 10/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/25/2021
Section Cited
CCR
87405(d)(2)

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87405 Administrator- Qualifications and Duties. (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
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Licensee to attend a training from an outside agency in regards to rules and regulations. Date and subject of training to be sent into CCL by 10/25/2021. Once training is completed administrator to send into CCL a copy of training certificate.
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This requirement is not met as evidenced by: Based on observation, Licensee was caring for clients in an unlicensed area of facility while continuing to run a Residential Care Facility for the Elderly, which is an potential risk to the health and safety of residents in care.
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Type B
11/25/2021
Section Cited
CCR87207

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87207 False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
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Licensee will submit a Letter of Understanding concerning being truthful with CCL during inspections and interviews.
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This requirement is not met as evidenced by: Based on interviews, Licensee was not truthful with CCL during inspection on 10/05/2021 which is a potential risk to the health and safety of 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:Anthony Perez
LICENSING EVALUATOR NAME:Jacob Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/11/2021 11:22 AM - It Cannot Be Edited


Created By: Jacob Williams On 10/11/2021 at 08:23 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: 10/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2021
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care. (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Licensee to submit to CCL a plan of how she will ensure all medications are locked and inaccessible to residents in care to CCL by 10/12/2021.
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This requirement is not met as evidenced by: Based on observation, Licensee did not ensure medications were locked which is an immediate threat to the health and safety of residents in care.
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Type A
10/12/2021
Section Cited
HSC1569.58(a)(2)

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1569.58 (a)(2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the state of California.
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Licensee to complete online orientation from CCL. Receipt of registration to be sent into CCL by 10/12/21. Once orientation has been completed a copy of certificate to be sent into CCL.
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This requirement is not met as evidenced by: Based on observation, Licensee was running an unlicensed operation in the "personal residency" area, which is an immediate threat to the health and safety of 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:Anthony Perez
LICENSING EVALUATOR NAME:Jacob Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2021


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Document Has Been Signed on 10/11/2021 11:22 AM - It Cannot Be Edited


Created By: Jacob Williams On 10/11/2021 at 08:29 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: 10/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2021
Section Cited
CCR
87468.1

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87468.1 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.
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Licensee to review PIN 21-38 and write a letter of understanding. Letter to be sent into CCL by 10/25/2021.
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This requirement is not met as evidenced by: Based on observation, Licensee did not wear face covering which is a potential risk to the health and safety of residents in care.
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Type B
11/11/2021
Section Cited
CCR87555(b)(26)

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87555 General Food Service Requirements. (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
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Licensee agrees to serve more fresh fruits and vegetables to residents in care. Administrator to send into CCL grocery receipts every Thursday for 30 days (until 11/11/2021).
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This requirement is not met as evidenced by: Based on observation, Licensee did not provide two-days worth of perishable foods, which is a potential risk to the health and safety of 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:Anthony Perez
LICENSING EVALUATOR NAME:Jacob Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: MINNESOTA HOME CARE
FACILITY NUMBER: 342700801
VISIT DATE: 10/11/2021
NARRATIVE
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During complaint investigation it was discovered administrator, Vera Okyere, was running an unlicensed operation in the “personal residence” part of the building. Administrator was providing care to 2 clients and living in the personal residence area. Administrator had a separate lease for the personal residence area and fire clearance was not granted for that area.
During complaint investigation interviews on 10/05/2021, administrator Vera Okyere stated that another individual was running and caring for clients in the unlicensed operation. During visit on 10/07/2021, administrator Vera Okyere admitted that she was in fact the individual running and caring for clients in the unlicensed operation and that she had lied to CCL.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC809 (FAS) - (06/04)
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