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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005577
Report Date: 07/26/2021
Date Signed: 07/26/2021 03:22:54 PM

Document Has Been Signed on 07/26/2021 03:22 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:REFINED SENIOR LIVINGFACILITY NUMBER:
347005577
ADMINISTRATOR:KRIEG, NERRYROSEFACILITY TYPE:
740
ADDRESS:7029 REFINED COURTTELEPHONE:
(916) 334-4910
CITY:SACRAMENTOSTATE: CAZIP CODE:
95842
CAPACITY: 6CENSUS: 6DATE:
07/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Nerryrose Krieg, AdministratorTIME COMPLETED:
03:30 PM
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On 7/26/21 Licensing Program Analyst (LPA) Praveen Singh arrived unannounced to conduct an annual required inspection utilizing the infection control domain. LPA met with Administrator and explained the purpose of the inspection. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Facility Representative and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA toured the facility inside and out including but not limited to living room, dining room, kitchen, bathroom, resident rooms, and outside areas. Facility has enough supplies of PPEs, paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every 30 days. While touring the laundry area, LPA observed unlocked cabinets filled with approx. 6-7 bottles and gallons of disinfectant supplies, including Awesome, Clorox, Oxi Clean, Ajax, Pine Sol and Odor Ban products.

Facility has enough 2-day perishable food and one-week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for residents and staff. LPA and Administrator completed the infection control domain.

Deficiencies cited from California Code of regulations, Title 22, and citations are listed on the attached LIC809-D. If the deficiency is not corrected by the noted due date civil penalties may be assessed. Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Praveen Singh
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2021
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 07/26/2021 03:22 PM - It Cannot Be Edited


Created By: Praveen Singh On 07/26/2021 at 02:59 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
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: REFINED SENIOR LIVING
FACILITY NUMBER: 347005577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
(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:
Deficient Practice Statement
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Based on LPA's observation on 7/26/21 at approximately 1:30 p.m., the licensee did not comply with the section cited above when LPA observed unlocked disinfectant supplies which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2021
Plan of Correction
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Licensee locked cabinets in LPA's presence. In addition, Licensee states a new facility policy will be put in place for additional oversight. Deficiency cleared during inspection.
Section Cited
Deficient Practice Statement
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POC Due Date: 07/26/2021
Plan of Correction
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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:Laura Munoz
LICENSING EVALUATOR NAME:Praveen Singh
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2021


LIC809 (FAS) - (06/04)
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