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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700856
Report Date: 11/26/2024
Date Signed: 11/26/2024 04:58:09 PM

Document Has Been Signed on 11/26/2024 04:58 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/
DIRECTOR:		ARGANA, FERDINANDFACILITY TYPE:
740
ADDRESS:8734 SOTHEBY CT.TELEPHONE:
(916) 267-5275
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 4DATE:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Maria Clardy, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 11/26/24 to conduct a Required-1 Year Inspection utilizing the inspection tool.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and seven (7) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 120 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed knives, cleaning products, and other toxins to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use.

LPA reviewed four (4) resident files and two (2) staff files. Facility has a current copy of certificate of liability insurance and LPA requested a copy.

As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiency is listed on the attached 809-D page.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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 11/26/2024 04:58 PM - It Cannot Be Edited


Created By: Michael Hood On 11/26/2024 at 04:36 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: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, facility did not ensure that all medications were kept in a locked storage inaccessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2024
Plan of Correction
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Facility placed all medications in a locked storage during visit. Facility will ensure that medications on the premises are kept locked and inaccessible to the residents in care at all times. Facility will conduct an in-service training regarding storage of medications and submit to LPA training materials and date of training by POC due date.
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:Anthony Perez
LICENSING EVALUATOR NAME:Michael Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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