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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700935
Report Date: 03/02/2023
Date Signed: 03/07/2023 10:33:02 AM

Document Has Been Signed on 03/07/2023 10:33 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BEATITUDES CARE HOMEFACILITY NUMBER:
392700935
ADMINISTRATOR:NOLASCO, RICKY C.FACILITY TYPE:
740
ADDRESS:1639 UNITED ST.TELEPHONE:
(209) 647-9701
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 6CENSUS: 5DATE:
03/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ricky NolascoTIME COMPLETED:
01:00 PM
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Unannounced annual visit made out to this facility on 03/02/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver Harveen Sidhu. This LPA requested that she go ahead and contact the facility designated Administrator to inform him that CCL was present at this time. The facility designated Administrator, Ricky Nolasco, was present and was briefly interviewed by this LPA at this time. Administrator certificate was reviewed for Ricky Nolasco and observed to have expired on 09/28/2022.
The facility designated Administrator stated that he was currently showing to be "Pending" and all documents and forms, including paid fee, have been submitted at this time.
Current census was 5 residents of which there weren't any residents under the care of hospice and no residents were under the care of home health. This facility does have an approved hospice waiver to accept and retain up to (3) hospice residents.
Tour of the facility was conducted.
Kitchen area was toured. Drawers and cabinets were reviewed. Cook ware, dinnerware, and utensils were observed to be sufficient and able to meet the needs of the residents at this time.
Food supply was reviewed for 2-day perishable and 7-day nonperishable food quantities.
Medication cabinet, located in kitchen area, was reviewed. A sample of the resident medications was compared with the facility Medication Administration Record and dispensing log initialed by the facility staff.
First aid kit was reviewed for required components and observed to contain all necessary components at this time.
Fire extinguisher, located under the kitchen sink, was observed to have been annually purchased and observed to be in compliance at this time.
Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in good repair at this time.
A tour of the facility resident rooms was conducted. Resident bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the facility resident restrooms was conducted. Hot water temperatures were taken and measured to
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2023
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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BEATITUDES CARE HOME
FACILITY NUMBER: 392700935
VISIT DATE: 03/02/2023
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make sure that they were within the allowed range of 105-120 degrees.
Grab bars were observed to be present and functional at this time.
Laundry area was toured. Detergents, bleach, and other cleaning agents were observed to be stored and maintained in a separate closet which was locked and made inaccessible to the residents at this time.
Linen closet was observed to contain a sufficient amount of linens and towels sufficient to meet the needs of the residents at this time.
Garage area was toured.
A tour of the exterior grounds was conducted.
Facility perimeter fence, side gates, and exits were reviewed.

The following forms were requested to be updated and submitted into CCL for review by this LPA:

LIC 308

LIC 400

LIC 500

LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules, and Regulations, Health and Safety Code.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
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Document Has Been Signed on 03/07/2023 10:33 AM - It Cannot Be Edited


Created By: Charlie Yang On 03/02/2023 at 12:08 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BEATITUDES CARE HOME
FACILITY NUMBER: 392700935

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation by this LPA, the licensee did not comply with the section cited above in that the exterior side gate was locked with a pad lock to not allow access in/out of this facility in case of any emergency since this was the sole exterior side exit which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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The facility designated Administrator stated that the side exterior gate will be unlocked, and maintained as such, at all times. A statement of correction, along with photos of the side gate that is unlocked, will be completed and submitted into CCL by the due date of 03/03/2023.
Additional photos of the updated fire extinguisher. located under the kitchen sink, will be submitted to show the most recent date of purchase.
Section Cited
Deficient Practice Statement
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POC Due Date:
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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023


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