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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002938
Report Date: 12/18/2024
Date Signed: 12/18/2024 04:07:11 PM

Document Has Been Signed on 12/18/2024 04:07 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:COZY HOME CAREFACILITY NUMBER:
345002938
ADMINISTRATOR/
DIRECTOR:		BRIONES, AIDA R.FACILITY TYPE:
740
ADDRESS:5643 CLARK AVE.TELEPHONE:
(916) 283-4142
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Judith DuncanTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 12/18/2024, Licensing Program Analyst (LPA) Cassie arrived unannounced at the facility to conduct a required annual visit utilizing the full care tool. LPA met with caregiver and explained the purpose of the visit.

Today's census is five residents in care with no residents on hospice services. Facility is in compliance to licensure.

During today's inspection, LPA and Caregiver conducted a tour of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to six private residents bedrooms, three bathrooms, staff room and the common areas.

LPA observed the facility to have the mandated posters posted in the common area. LPA observed facility having seven days of non perishables in the pantry, LPA observed toxins to be locked and inaccessible to residents in care. Facility thermostat was set at a comfortable temperature. LPA observed carbon monoxide alarm to be working. LPA observed medication to be pre-poured in a cup set on the kitchen table. LPA was informed it was being prepared for dinner in the next hour.

LPA and Caregiver discussed ensuring the emergency exit door is never blockade.

LPA conducted file review and observed the required documents present. LPA reviewed facility Emergency Disaster Plan and observed it to be reviewed on 11/14/2024 by Administrator. At this time, LPA is requesting a copy of liability insurance and LIC 500 to be emailed to LPA by December 23, 2024.

Care tool was completed and deficiencies cited. Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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 12/18/2024 04:07 PM - It Cannot Be Edited


Created By: Cassie Yang On 12/18/2024 at 03:22 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: COZY HOME CARE
FACILITY NUMBER: 345002938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA observed residents medications pre-poured on the table to be given with dinner meals, which poses a potential risk for residents in care.
POC Due Date: 12/23/2024
Plan of Correction
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Medications were immediately relocated.
Licensee is to submit a plan of facility's medication administration procedure of how medication are to be given to residents in care without violating Title 22.
POC is due 12/23/2024, failure to correct may result to $100 per day until received.
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:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024


LIC809 (FAS) - (06/04)
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