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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004245
Report Date: 10/15/2024
Date Signed: 10/15/2024 11:18:33 AM

Document Has Been Signed on 10/15/2024 11:18 AM - 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/
DIRECTOR:		MARRI EDQUIDFACILITY TYPE:
740
ADDRESS:9445 MAINLINE DRIVETELEPHONE:
(916) 690-8932
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
10/15/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Aida GatchalianTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
NARRATIVE
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On 10/15/24, at 9:30am, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit. LPA initially met with one of the staff on duty (S1) and stated the purpose of the visit. The Licensee, Aida Gatchalian, was notified of this visit and arrived shortly after. Present during today's visit were 6 residents in care with 2 staff on duty (S1 and S2).

During this visit, LPA Villanueva conducted an inspection of the facility, which included the living room, family room, bathroom, kitchen/dining area, bedrooms, and garage. In the family room, three residents were observed watching TV. While inspecting one of the bathrooms, LPA observed a spray cleaning bottle on the toilet seat and a cleaning solution on the floor, for which a photo was taken. At that time, S1 was assisting a resident in the dining area, while S2 was aiding another resident in their bedroom.

The facility features a three-car garage, which was inspected. The right side of the garage was sectioned off with cabinets, which contained clothing belonging to the owner, as confirmed by S1. In this area, LPA also observed four mattresses propped upright against the wall, along with luggage and boxes. Near the exit door leading outside, a lounge chair and a shoe organizer filled with shoes were noted. Additionally, the garage contained refrigerators and various food supplies. The left side of the garage has couches which is covered with white sheet and boxes of incontinent supplies.

While inspecting the kitchen refrigerator, LPA found three bottles of medication (M1) placed in a plastic Ziploc bag labeled with a resident's name on the left door storage shelf. On the right door's top shelf, another medication (M2) belonging to a different resident was observed, along with a medication (M3) that belonged to the Licensee.



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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MAINLINE HOME CARE
FACILITY NUMBER: 347004245
VISIT DATE: 10/15/2024
NARRATIVE
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Interviews were conducted with S1 and the Licensee during the visit. Both confirmed that no staff members are using the garage as a bedroom. The Licensee indicated they work the night shift from 7 AM to 7 PM to provide overnight supervision, emphasizing that they do not have live-in staff. Further interviews clarified that the mattresses stored in the garage belonged to residents prior to them acquiring hospital beds. The couches that were previously in the family room have been relocated to the garage, as residents now have their own reclining chairs.

During the discussion with the Licensee, they expressed their commitment to cleaning and organizing the garage to ensure it does not appear to be used other than as a garage. The Licensee assured LPA that they would inform the Department in advance if they ever decide to convert the area into a room or an office.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

During the exit interview conducted with Aida Gatchalian, LPA read this report and discussed deficiencies and plan of corrections and and a copy of this report and appeal rights were provided.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/15/2024 11:18 AM - It Cannot Be Edited


Created By: Arvin Villanueva On 10/15/2024 at 10:47 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: 10/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2024
Section Cited
CCR
87465(h)(2)

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(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Licensee to submit a written statement of understanding of the regulation cited and submit statement to the Department by POC due date.
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This requirement is not met as evidenced by:
Based on observation, licensee did not comply with the regulation noted above. It was observed that 3 medications were stored in the kitchen refrigerator. This poses an immediate health and safety
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Per discussion with Licensee, they have agreed to provide staff training on proper medication storage. Licensee will submit completed training by end of day on 10/25/24.
Per Licensee they will obtain a locked box and will store the locked box in the garage refrigerator.
Type A
10/16/2024
Section Cited
CCR87705(f)(2)

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(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Licensee to submit a written statement of understanding of the regulation cited and submit statement to the Department by POC due date.
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Based on observation, licensee did not comply with the regulation noted above. During inspection of one bathroom, LPA observed cleaning supplies on the floor and on top of the toilet seat cover. This poses an immediate health and safety
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Per discussion with Licensee, they have agreed to provide staff training on proper storage of dangerous items and chemicals. Licensee will submit completed training by end of day on 10/25/24.
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: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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