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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004245
Report Date: 03/05/2024
Date Signed: 03/05/2024 12:11:02 PM

Document Has Been Signed on 03/05/2024 12:11 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:MAINLINE HOME CAREFACILITY NUMBER:
347004245
ADMINISTRATOR:MARRI EDQUIDFACILITY TYPE:
740
ADDRESS:9445 MAINLINE DRIVETELEPHONE:
(916) 690-8932
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
03/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Aida GatchalianTIME COMPLETED:
12:15 PM
NARRATIVE
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On 3/5/2024, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to conduct a case management visit. LPA initially met with a staff on duty and explained the purpose of the visit. The facility administrators, Aida Gatchalian and Ma Magnolia Tolon, were notified of this visit and arrived shortly after.
Present during this visit are 3 residents in care with 2 staff on duty.

The purpose of this visit was to follow up on an exception request regarding Resident 1(R1).

LPA reviewed R1's facility file including but not limited to Pre-Appraisal, Needs and Services Plan and Physician's Report. It was learned through record review and interviews that the resident has been using indwelling Foley catheter continuously since November 2023 without an exception request. The needs and services plan dated on 3/20/2023 states that R1 is on and off on the use of Foley catheter. In addition, a review of the resident's home health notes indicates that R1 has been seen for routine catheter changes since 11/1/23 and R1 gets routine catheter changes every 4 weeks.

Based on interviews conducted, it was learned that the resident does not clean their catheter and needs staff assistance at this time. Aida and Ma Magnolia stated that they were not aware that an exception request was needed to be sent to the department for the use of catheter.

Based on the information gathered during the course of this visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, the following deficiencies are being cited today in violation of California Code of Regulations.
An exit interview was conducted with Aida and Ma Magnolia and a copy of this report and appeals rights were provided to the facility at the end of this visit.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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 03/05/2024 12:11 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 03/05/2024 at 11:40 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: MAINLINE HOME CARE
FACILITY NUMBER: 347004245

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2024
Section Cited
CCR
87611(a)

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87616 Exceptions for Health Conditions: (a) ... the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.
This is not met as evidenced by:
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Licensee has already submitted an exception request for catheter to the Department and awaiting for Department approval.
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Based on interviews and record review the Licensee did not ensure that a written request for an exception was sent to the Department for approval as soon as R1 started using a catheter. This poses an immediate, health, safety, and personal rights risks to persons in care.
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Licensee to submit a statement of understanding of the regulation related to restricted/prohibited health conditions to the Department by the POC due date.
Type B
03/12/2024
Section Cited
CCR87405(d)(2)

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(d) The administrator shall have...
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

This is not met as evidenced by:
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The licensee shall provide a statement of understanding regarding the following regulation 87405(d)(2) to the Department by the POC date.
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 Based on interview and record review, the licensee did not ensure that the facility obtained an exception request for R1's indwelling catheter as soon as R1 started using catheter.
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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: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
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