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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003137
Report Date: 09/04/2024
Date Signed: 09/04/2024 03:43:57 PM

Document Has Been Signed on 09/04/2024 03:43 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:LA FIELD HOME CAREFACILITY NUMBER:
347003137
ADMINISTRATOR/
DIRECTOR:		PEREBIKOVSKIY, GALINAFACILITY TYPE:
740
ADDRESS:5729 LA FIELD DRIVETELEPHONE:
(916) 965-7713
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 4DATE:
09/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Galina Perebikovskiy, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility unannounced on 9/4/24 to conduct an annual continuation visit utilizing the inspection tool following the Required-1 Year Inspection conducted on 9/3/2024. LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations.

During today's visit, LPAs reviewed quarterly drill log and conducted interviews with two (2) staff and two (2) residents.

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 809-D page.

Exit interview was conducted with Administrator. 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: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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 09/04/2024 03:43 PM - It Cannot Be Edited


Created By: Michael Hood On 09/04/2024 at 03:31 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: LA FIELD HOME CARE
FACILITY NUMBER: 347003137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(c)
(c) The items specified in (a) above shall not be stored in food storage areas or in storage areas used by or for clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs' observations, facility did not ensure that food was stored separately from disinfectants, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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Facility cleared deficiency during visit. LPA cleared deficiency at the conclusion of this visit.
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: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024


LIC809 (FAS) - (06/04)
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