342701286-7-16-2025-27-AS-AVIA-DJMVX3-20250716164853

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701286
Report Date: 07/16/2025
Date Signed: 07/16/2025 04:48:59 PM

Document Has Been Signed on 07/16/2025 04:48 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	BEATRICE HOME CARE		FACILITY NUMBER:	342701286
ADMINISTRATOR/ DIRECTOR:	CLARK, BEATRICE		FACILITY TYPE:	740
ADDRESS:	1014 FERNANDO WY		TELEPHONE:	(916) 270-3961
CITY:	GALT	STATE: CA	ZIP CODE:	95632
CAPACITY: 6		CENSUS: 6	DATE:	07/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Beatrice Clark		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/16/2025, Licensing Program Analysts, Kimberly Viarella and Arvin Villanueva (LPAs) arrived unannounced at this facility to conduct their annual inspection visit. LPAs initially met with staff on duty (S2) and stated the purpose of the visit. The Administrator Beatrice Clark (S1) was notified and arrived later. Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents. 5 may be non-ambulatory. Bedrooms 1, 2, 3 and Master bedroom approved for non-ambulatory. Bedroom 4 approved for ambulatory only. Facility has hospice waiver for 2 residents. Initial Observation: Upon arrival, LPAs observed 3 residents having their morning meal at the dinning table. Present during this visit were 6 residents in care with 1 staff on duty (S2). There was an outside agency staff assisting one resident. The room temperature was at 72 degrees Fahrenheit. Physical Inspection and Operational: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA inspected 5 resident bedrooms. Master bedroom is occupied by 2 residents. Bedroom #4 is currently being occupied by a non-ambulatory resident. LPA measured the hot water temperature in the 1 of 2 bathrooms to be at 107 degrees Fahrenheit. The light switch in the hallway bathroom was observed to be in disrepair. Also inside the hallway bathroom, LPAs found scissors under the sink cabinet, unlocked and accessible to residents in care. The bathroom inside the master bedroom, LPAs found a disinfectant spray inside the sink cabinet that was unlocked and accessible to residents. Also inside the bathroom in the master bedroom, LPAs observed the shower area to not equipped with grab bars. The master bedroom bath also has a closet which contains 2 Hoyer lifts. {Con't to 809-C}

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 26

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 26

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BEATRICE HOME CARE	FACILITY NUMBER: 342701286
	VISIT DATE: 07/16/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

{Con't from 809} Fire extinguisher was observed in the kitchen area and hallway and was last inspected on 4/15/2024. Smoke and carbon monoxide detectors were observed throughout, tested and found operable during this visit. Fire door leading to the resident bedrooms were observed to be propped open with a sandal.
In the kitchen area, LPA observed sufficient seven day non-perishable and two day perishable food supplies. Pantry was observed to be stocked with non-perishable food items. Kitchen refrigerator and freezer were maintained at regulatory temperature. Inside the kitchen refrigerator, LPAs found resident medication that was accessible to residents in care. Per interview with S1, staff lock the refrigerator. During this visit, S1 purchased a lock box for the medication.
Outdoor area was inspected. LPA observed outdoor furniture for resident use. Ramps were observed to be in good repair at this time. Emergency walkways were observed to be unobstructed. Fence and gates were in good repair at this time.

Record Reviews:
Review of 6 of 6 resident files (R1 - R6) was conducted, include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. LPAs noted some issues.
Medication review of 4 of 6 residents include review of physician orders for over-the-counter medications. LPAs noted some issues. Per S1, they do not have Centrally Stored Medication Record available for review during this visit.
Review of 2 staff files (S1 and S2) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. S2 did not have a current first aid certificate on file available for review during this visit.
Fire drill/disaster drill records were not available for review during this visit. Infection Control Plan and Emergency Procedure Plan were not available for review during this visit.
First Aid kit was reviewed and found to be incomplete at this time: needs bandages and first aid manual.
LPA was provided a copy of current Liability Insurance Certificate, LIC500 and LIC308 during this visit.

Interviews:
LPA interviewed 2 staff and 2 residents during this visit.

Based on today's visit, this annual needs continuation. Exit interview was conducted with S1. A copy of the report was provided upon exit.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025

LIC809 (FAS) - (06/04)

Page: 3 of 26