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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700801
Report Date: 11/14/2024
Date Signed: 11/14/2024 02:57:58 PM

Document Has Been Signed on 11/14/2024 02:57 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:MINNESOTA HOME CAREFACILITY NUMBER:
342700801
ADMINISTRATOR/
DIRECTOR:		OKYERE, VERA A.FACILITY TYPE:
740
ADDRESS:7448 MINNESOTA DR.TELEPHONE:
(916) 729-9461
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 3DATE:
11/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Vera Okyere, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a follow up case management inspection and met with Vera Okyere, Administrator. LPA stated the reason for the inspection. There are currently (3) residents who live at the home, but (1) resident went to the hospital last night. Currently there are (0) residents receives hospice care.

LPA previously conducted a related case management inspection, on 9/25/24, and discussed resident (R1's) personal property and (R1) being sent to the emergency room on 9/11/24. The Administrator provided documentation related to (R1's) property and receipts for clothing, medication and rent and care charged from 8/26/24- 9/26/24.

The Administrator provided additional documentation by e-mail, as requested, on 9/26/24, showing funds belonging to (R1) had been co-mingled with Licensee's funds. Resident's family member removed (R1's) belongings from his room on 9/30/24, and the Administrator mailed a check for personal funds belonging to (R1) on 10/1/24, which was received on 10/3/24. The physician's report indicates (R1) has a diagnosis of Dementia and requires assistance in managing his own cash resources. LPA and Administrator discussed how a surety bond is required in order to handle residents' funds, and the department was not notified.

During today's inspection, LPA and Administrator discussed how (R1) did not sign the Admission Agreement when moving in on 8/26/24 and that (R1) was charged for 1:1 care, following being sent to the hospital on 9/11/24, and not returning to the facility, as he passed in the hospital on 9/21/24. LPA requested documentation showing a 1:1 staff was provided to (R1) from 8/26/24 until 9/11/24, when (R1) was sent to the emergency room.

Per California Code of Regulations Title 22, Division 6, Chapter 8, the following (4) deficiencies are issued on the 809-D pages, as well as a Technical Advisory Note.
Exit interview. Copy of report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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 11/14/2024 02:57 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 11/14/2024 at 10:59 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: MINNESOTA HOME CARE
FACILITY NUMBER: 342700801

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/29/2024
Section Cited
CCR
87217(e)

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87217 Safeguards for Resident Cash, Personal Property, and Valuables. (e) Cash resources and valuables of residents which are handled by the licensee for safekeeping shall not be commingled with or used as the facility funds or petty cash, and shall be separate, intact and free from any liability the licensee incurs in the use of his own or the facility's funds and valuables. This does not prohibit the licensee from providing advances or loans to residents from facility money. This requirement is not met as evidenced by:
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The Administrator issued a check to (R1's) responsible person for funds belonging to (R1) on/around 10/1/24, following (R1's) passing on 9/21/24.

The Administrator agrees to read Regularion 87217 and submit a statement in writing that it is understood by 11/29/24.
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Based on interviews conducted and documentation reviewed, including bank documentation, the Licensee did not ensure that (R1's) personal funds were not comingled with the Licensee's funds,
as they were deposited into an account belonging to the Licensee on 8/27/24,
which posed an immediate health and safety risk to residents in care.
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Type B
12/02/2024
Section Cited
CCR87507(f)

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87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by:
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The Licensee agrees to refund the portion charged for 1:1 care, from 9/12/24 to 9/26/24, to (R1's) family member.

Will issue refund to (R1's) family member by 12/2/24.
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Based on interviews conducted and documentation reviewed, the Licensee did not comply with providing 1:1 care, as charged, for the period, 9/12/24- 9/26/24, as (R1) was sent to the emergency room on 9/11/24 and did not return to the facility as (R1) passed in the hospital on 9/21/24, which posed a potential health and safety risk to 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:Maribeth Senty
LICENSING EVALUATOR NAME:Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2024 02:57 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 11/14/2024 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MINNESOTA HOME CARE
FACILITY NUMBER: 342700801

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2024
Section Cited
CCR
87507(c)

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87507 Admission Agreements.
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
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Licensee agrees to ensure all current/future Admission Agreements have been/will be signed by the resident, or responsible person.

Admin agrees to submit a signed statement that all agreements have at least 2 signatures and Reg 87507 is read and understood- submit by 11/28/24. .
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Based on documentation review, the Licensee did not ensure the Admission Agreement was signed by (R1) and/or the responsible person, which posed a potential health and safety and/or personal rights risk to residents in care. (R1) was not conserved, did not have a legal responsible person and had a diagnosis of Dementia. Administrator stated you told (R1) the amount of rent being charged because (R1) refused to sign.
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Type B
11/29/2024
Section Cited
CCR87216(d)

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87216 Bonding (d) No licensee shall either handle money of a resident or handle amounts greater than those stated in the affidavit submitted by him or for which his bond is on file without first notifying the licensing agency and filing a new or revised bond as required by the licensing agency. This requirement is not met as evidenced by:
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Licensee agrees to read Regulation 87216 and submit a signed statement of its understanding by 11/28/24.
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Based on an interview with the Administrator, the Licensee did not ensure that the Department was notified and a bond was filed for, before handling (R1's) personal funds, which posed a potential health and safety and/or personal rights risk to the clients 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:Maribeth Senty
LICENSING EVALUATOR NAME:Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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