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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003884
Report Date: 05/15/2024
Date Signed: 05/21/2024 03:28:15 PM

Document Has Been Signed on 05/21/2024 03:28 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:TAHOE, THEFACILITY NUMBER:
347003884
ADMINISTRATOR/
DIRECTOR:		DESCARGAR, BERNADETTEFACILITY TYPE:
740
ADDRESS:8708 SECKEL COURTTELEPHONE:
(916) 686-5715
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
05/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Bernadette DescargarTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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{This is an amended version of the report originally created on 5/15/24}

On 5/15/24, at 11:30am, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management visit. LPA met with the facility administrator, Bernadette Descargar, and explained the purpose of the visit. Present during this visit, were 5 residents in care with 3 staff on duty. Additionally, an outside agency was also present assisting some residents in care.

During a complaint visit on 5/6/24 (complaint #27-AS-20240429152716), it was observed during an inspection of residents’ beddings that two pillows of one resident in care were covered with white plastic bags, then covered with pillowcase on top. Per interview with staff, the white plastic garbage bags were being used as pillow protectors in case of accidental incontinence. Staff on duty immediately removed the plastic garbage from the pillows. Staff stated they will purchase pillow protectors for resident’s pillows.

During this visit, LPA observed pillowcases were covered with pillow protectors.

As a result of this case management, the following deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted with Bernadette and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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 05/15/2024 12:17 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 05/15/2024 at 11:59 AM
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: TAHOE, THE
FACILITY NUMBER: 347003884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2024
Section Cited
CCR
87307(a)(3)(C)

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87307(a)(3)(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths…The linen shall be in good repair.
This requirement is not met as evidenced by:
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Corrected prior to this visit:
Licensee purchased pillow protectors for residents in care.
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Based on observation and interview, the licensee did not comply with the regulation noted above. During bedding inspection of one resident, it was discovered that plastic garbage bags were being used as pillow protectors for resident's pillow which poses a potential health, safety or personal rights risk to persons in care.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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