Community Care Licensing

Document Has Been Signed on 07/12/2023 02:49 PM - It Cannot Be Edited

FACILITY NAME:	A & C CARE HOME #2		FACILITY NUMBER:	347005161
ADMINISTRATOR:	SUAYBAGUIO, CECILIA		FACILITY TYPE:	740
ADDRESS:	3601 GARFIELD AVE.		TELEPHONE:	(916) 993-8755
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY: 6		CENSUS: 5	DATE:	07/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Caregiver		TIME COMPLETED:	03:00 PM

SUPERVISORS NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023

Link to Parent Document Below:

FACILITY NAME: A & C CARE HOME #2	FACILITY NUMBER: 347005161
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/12/2023

Type B

Section Cited

CCR

87470(c)

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and interview, the licensee did not comply with the section cited above in not submitting the required infection control plan required since 2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2023
	Plan of Correction
1 2 3 4	Licensee will submit and infection control plan for approval by the poc date of 8/2/23.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023

Link to Parent Document Below:

FACILITY NAME: A & C CARE HOME #2	FACILITY NUMBER: 347005161
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/12/2023

Type B

Section Cited

CCR

87467(a)(3)

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviews, the licensee did not comply with the section cited above in 5 of 5 resident files file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/26/2023
	Plan of Correction
1 2 3 4	Licensee will submit the plan/ appointments for when the plans will be reviewed and signed. All meetings shall happen before 8/12/23.

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023

Link to Parent Document Below:

FACILITY NAME: A & C CARE HOME #2	FACILITY NUMBER: 347005161
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/12/2023

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in records of quarterly drills have not been recorded for the past 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2023
	Plan of Correction
1 2 3 4	Licensee will submit a completed drill that includes all caregivers as well as plan for regular drills to CCL by the poc date pf 7/19/23

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Maribeth Senty LICENSING EVALUATOR NAME: Kevin Mknelly LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023