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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002902
Report Date: 10/19/2022
Date Signed: 10/19/2022 03:29:37 PM

Document Has Been Signed on 10/19/2022 03:29 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:UNITY MEMORY HOME CAREFACILITY NUMBER:
345002902
ADMINISTRATOR:LIU, YINGFACILITY TYPE:
740
ADDRESS:8161 CHIMANGO COURTTELEPHONE:
(916) 301-8792
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 4DATE:
10/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ying Liu (Ruby) TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains and Licensing Program manager (LPM) Laura Munoz arrived at the facility unannounced on 10/19/22 and met with administrator Ying Liu (Ruby). Prior to the visit , LPA and LPM completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA and LPM wore the following Personal Protective Equipment (PPE) during today's visit-surgical masks. LPA and LPM were screened by facility staff upon entry.

During facility tour, LPA and LPM observed that R1 is bedridden. A review of R1's medical assessment dated 05/26/2022 indicated R1's ambulatory status as "bedridden". Upon review, the facility does not have approved fire clearance for bedridden residents. R1 indicated she is able to rotate herself however is unable to do so with the current bed she has. LPA and LPM observed R1 in a hospital bed not equipped with mobility assisted devices to assist R1 to rotate. In addition, LPA and LPM observed R1 does not have a wheelchair accessible to her therefore, R1 is unable to be transferred in and out of bed. Lastly, it is noted in R1's records and observed by LPM that R1 has pressure sores on coccyx area as well as left heel. Per facility staff, home health has been coming to the facility to manage wound care.

The facility accepted a resident who was bedridden without proper fire clearance which poses a immediate health and safety risk to residents in care. Immediate civil penalty in the amount of $500 is assessed today and citations issued per Title 22, CCR. Furthermore, the facility not preserve R1's personal rights when the facility failed to provide R1 is mobility assistance equipment to assist R1 in rotating and transferring. This violation is an immediate safety risk to residents in care. Citation-A issued to the facility per Title 22,CCR.

The licensee stated that the facility will replace R1's bed on 10/21/2022 with a bed that has bed rails. In addition, the licensee provided R1 with a wheelchair at the time of LPA and LPMs visit today.
Appeal rights provided. Exit interview conducted with Ruby and copy of the report left at facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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 2
Document Has Been Signed on 10/19/2022 03:29 PM - It Cannot Be Edited


Created By: Talwinder Bains On 10/19/2022 at 01:43 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: UNITY MEMORY HOME CARE
FACILITY NUMBER: 345002902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2022
Section Cited
CCR
87202(a)(2)

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87202-Fire Clearance-(a)All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
(1) Nonambulatory persons.
(2) Bedridden persons
This requirement is not met as evidence by:
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Licensee will submit a plan to CCL indicating if the licensee will submit a request to obtain bedridden fire clearance. If the licensee does not request bedridden fire clearance, the licensee will submit a plan on how the facility will assist R1 in relocating to a facility with approriate fire clearance.
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The facility admitted R1 to the facility with documentated bedridden ablulayory stauts. The facility does not have fire clearnce for bedridden residents which poses a immedidate health and safety risks to residents in care.
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Plan shall be submitted by, 10/21/2022
Type A
10/21/2022
Section Cited
CCR87468.1(a)(2)

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87468-Personal Rights-(a) Residents in residential care facilities for the elderly shall have personal rights which include, but are not limited to, Personal Rights of Residents in All Facilities, and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. This requirement is not met as evidence by:
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Licensee provided the R1 a wheelchair at the time of visit. The Licensee will submit photographs by POC date of R1's new bed with mobility assistive devices. In addition, the licensee will submit a plan on how staff will ensure R1 is rotated every 2 hours due to R1's bedridden status.
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LPA and LPM observed that R1 does not a wheel chair and no side rails for mobility which poses a immediate health and safety risks to residents in care.
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POC shall be submitted by, 10/21/2022
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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022


LIC809 (FAS) - (06/04)
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