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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002823
Report Date: 10/02/2024
Date Signed: 10/02/2024 02:36:10 PM

Document Has Been Signed on 10/02/2024 02:36 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:WHOLESOME ELDERLY ON KIFISIAFACILITY NUMBER:
345002823
ADMINISTRATOR/
DIRECTOR:		FAAMAUSILI,CHRISFACILITY TYPE:
740
ADDRESS:6024 KIFISIA WAYTELEPHONE:
(916) 678-0268
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 5DATE:
10/02/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Juliet Wilson, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility unannounced on 10/2/24 to conduct an annual continuation visit utilizing the inspection tool following the Required-1 Year Inspection conducted on 9/20/2024. LPAs met with caregiver, Juliet Wilson, and spoke with Administrator, Juan Ramirez, by phone call. Administrator gave permission to have caregiver sign report.

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are five (5) bedrooms and two (2) bathrooms for resident use. LPAs 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 119.2 degrees F.

LPAs 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. LPAs observed knives, cleaning products, and other toxins to be locked away and inaccessible to residents. LPAs observed the backyard and perimeter of the care home to be free of clutter and debris. LPAs observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use.

As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are listed on 809-D page. An immediate civil penalty in the amount of $500 was assessed for today's date due to a body of water being accessible to residents in care on the premises.

Exit interview was conducted with caregiver. 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: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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 10/02/2024 02:36 PM - It Cannot Be Edited


Created By: Michael Hood On 10/02/2024 at 02:05 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: WHOLESOME ELDERLY ON KIFISIA
FACILITY NUMBER: 345002823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(e)
Personal Accommodations and Services
(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs' observations, facility did not ensure to keep pool on the premises locked and inaccessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2024
Plan of Correction
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Facility placed lock on unlocked gate to pool during inspection. Facility will ensure that pool on the premises is locked at all times. Facility will complete a statement of understanding regarding regulation 87307 and submit statement to LPA by POC due date. An immediate civil penalty in the amount of $500 is assessed for a body of water being accessible to residents in care.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs' observations and records reviewed, the facility did not ensure to document start dates for medications administered, which poses an immediate health, safety or personal rights risk to persons in care. LPAs' also observed loose, unidentified medications in the residents' medication storage units.
POC Due Date: 10/03/2024
Plan of Correction
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Facility will use centrally stored medication (CSMF) form to document medications administered. Facility will submit completed CSMF for all residents to LPA by POC due date.
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: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/02/2024 02:36 PM - It Cannot Be Edited


Created By: Michael Hood On 10/02/2024 at 02:05 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: WHOLESOME ELDERLY ON KIFISIA
FACILITY NUMBER: 345002823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024

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 on LPAs' observations, facility did not ensure to keep centrally stored medications locked and inaccessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2024
Plan of Correction
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Facility locked unlocked medication storage during visit. Facility will ensure that centrally stored medication is locked and inaccessible to the residents in care at all times. Facility will complete a statement of understanding regarding regulation 87465 and submit statement to LPA 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: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


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Document Has Been Signed on 10/02/2024 02:36 PM - It Cannot Be Edited


Created By: Michael Hood On 10/02/2024 at 02:08 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: WHOLESOME ELDERLY ON KIFISIA
FACILITY NUMBER: 345002823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)
87458 Medical Assessment

(c) The licensee shall obtain an updated medical assessment when required by the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, LPAs observed that resident (R1) only had one (1) medical assessment for 6/3/2022 when they were placed on hospice and graduated from hospice following their last assessment, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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LPA is requesting that facility obtain a new medical assessment for R1 following a change in condition. Facility will submit completed current medical assessment for R1 to LPA by POC due date of 10/17/2024.
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: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


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