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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005412
Report Date: 01/21/2025
Date Signed: 01/21/2025 01:21:12 PM

Document Has Been Signed on 01/21/2025 01:21 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:VIRGINIA DENISE COUNTRY HOMEFACILITY NUMBER:
347005412
ADMINISTRATOR/
DIRECTOR:		FERMO, AILEENFACILITY TYPE:
740
ADDRESS:2305 VIRGINIA DENISE LANETELEPHONE:
(916) 813-0460
CITY:RIO LINDASTATE: CAZIP CODE:
95673
CAPACITY: 6CENSUS: 4DATE:
01/21/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Aileen FermoTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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On 1/21/2025, Licensing Program Analysts (LPAs) Cassie Yang and Kayla Adkison arrived unannounced at the facility to conduct a case management visit regarding the recent Title 17 monitoring review conducted on 12/17/2024. LPAs met with Administrator and explained the purpose of the visit.

LPAs and Administrator discussed the deficiencies observed by Alta California Regional Center. Administrator stated prescribed medication was administered to C1 but staff had failed to document the following in C1's medication administration record. Administrator stated during date of administration, there was "chaos" in the morning routine which caused facility staff to failed signing the last medication.

Administrator informed LPAs in-service training has been conducted to ensure the 7 Rights of Medication Administration.

As a result of today's visit, deficiencies cited.

Exit interview conducted, and a copy of the report and appeal rights provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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 01/21/2025 01:21 PM - It Cannot Be Edited


Created By: Cassie Yang On 01/21/2025 at 01:09 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: VIRGINIA DENISE COUNTRY HOME
FACILITY NUMBER: 347005412

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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Licensee conducted an in-service training of 7 Rights of Medication to all staff.

Correction will be cleared.
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Based on file review, the Licensee did not comply as C1's prescribed medication was not signed off as administered for 12/15/2024, which poses a potential risk for residents 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:Anthony Perez
LICENSING EVALUATOR NAME:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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