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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700856
Report Date: 03/06/2024
Date Signed: 03/06/2024 03:45:15 PM

Document Has Been Signed on 03/06/2024 03:45 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:A HEARTY CARE HOME IVFACILITY NUMBER:
342700856
ADMINISTRATOR:ARGANA, FERDINANDFACILITY TYPE:
740
ADDRESS:8734 SOTHEBY CT.TELEPHONE:
(916) 267-5275
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 4DATE:
03/06/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Maria Clardy, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility to conduct a health and safety check and follow-up regarding technical assistance that was provided to the facility during an inspection conducted on 11/28/2023.

During today's inspection, LPA toured the facility and conducted a file review for four (4) staff and four (4) resident files.

As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8 regarding hazardous items being accessible to residents and staff missing health screenings on file.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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 03/06/2024 03:45 PM - It Cannot Be Edited


Created By: Michael Hood On 03/06/2024 at 03:03 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: A HEARTY CARE HOME IV
FACILITY NUMBER: 342700856

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2024
Section Cited
CCR
87309(a)

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
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Facility will ensure that all hazardous items are locked and inaccessible to the residents in care at all times. Administrator will complete a statement of understanding regarding regulation 87309 and submit to LPA by POC due date of 3/7/2024.
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Based on LPA's observation, facility did not ensure that knives and cleaning products were inaccessible to residents in care, which poses an immediate health, safety, and personal rights risk to the residents in care.
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Type B
04/04/2024
Section Cited
CCR87412(a)(11)

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87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on (...) each employee. Each personnel record shall contain (...) (11) A health screening as specified in Section 87411 (...). This requirement is not met as evidenced by:
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Facility will obtain health screenings for all staff. Facility will submit a copy of each employee's health screening to LPA by POC due date of 4/4/2024.
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Based on records reviewed, the facility did not ensure that 2 of 4 staff records included a health screening, which poses a potential health, safety, and personal rights risk to the 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:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
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