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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701156
Report Date: 05/03/2023
Date Signed: 05/03/2023 12:42:48 PM

Document Has Been Signed on 05/03/2023 12:42 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:NANTUCKET RESIDENCE, THEFACILITY NUMBER:
392701156
ADMINISTRATOR:GESMUNDO, PAOLOFACILITY TYPE:
740
ADDRESS:3232 WISCONSIN AVETELEPHONE:
(209) 636-3456
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 6CENSUS: 5DATE:
05/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Orchid DamrichobTIME COMPLETED:
12:50 PM
NARRATIVE
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On 5-3-23 at 9:46am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Orchid Damrichob and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed residential care facility for the elderly with a current census of 5. Facility has 4 bedrooms and 2 bathrooms for resident use. Facility has a formal dining room and a formal living room. LPA also conducted the inspection using the CARE tool. Facility currently provides care for 0 bedridden, 2 hospice, 5 non-ambulatory (total residents), and 0 ambulatory residents.
The facility has an approved COVID Mitigation plan LIC 808 form in place. The facility conducts routine symptom screening for employees, residents, and visitors as necessary. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility. The facility has a designated infection control lead. Common touch surfaces are cleaned after each use.

Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 78*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 2-17-23. Facility has an emergency food and water kit. LPA observed toxins unsecured in an outside shed during tour. LPA also observed a broken window screen on the left side of facility property. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed and contained accompanying regulatory required Physician’s orders. First aid kit was observed to have adequate supplies and accessible to staff. {Cont. on 9099C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156
VISIT DATE: 05/03/2023
NARRATIVE
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During this inspection 5 resident files and 4 staffing files were reviewed for regulatory compliance. Staffing files did not contain evidence of completed regulatory training requirements for staff including general staff training and medication training requirements. All staff noted on LIC 500 contained criminal background clearances. LPA completed 2 resident interviews and 2 staff interviews. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility’s liability insurance is current and update to date per regulatory requirements. Facility does not contain any bodies of water. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. Facility has 1 resident with bedrails with physician orders in place. LPA requested an updated copy of LIC 308 and LIC 500.

Per California Code of Regulations, Title 22 and health and safety codes, deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Orchid Damrichob. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/03/2023 12:42 PM - It Cannot Be Edited


Created By: Michael Bilger On 05/03/2023 at 11:38 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA observed various toxins stored in unlocked shed in backyard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2023
Plan of Correction
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Licensee secured shed with lock during LPA's visit.

Licensee to provide staff training on regulation 87309(a) and submit proof of completed training to LPA by POC due date
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:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/03/2023 12:42 PM - It Cannot Be Edited


Created By: Michael Bilger On 05/03/2023 at 11:38 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA observed window screen on side of facility detached and unsecured which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Licensee will repair or replace window screen and send photo proof of completion to LPA by POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 4 out of 4 staffing charts reviewed. Staffing charts did not contain evidence of regulatory required staff training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Licensee will ensure the completion of the 20 hours of required staff training and send proof of completed training to LPA by POC due date.
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:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/03/2023 12:42 PM - It Cannot Be Edited


Created By: Michael Bilger On 05/03/2023 at 11:38 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NANTUCKET RESIDENCE, THE
FACILITY NUMBER: 392701156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 4 out of 4 staffing charts reviewed. Licensee did not ensure completed medication training for staff who handle medication until 3/25/23 and licensee began operation on 5-3-22, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Licensee will read regulation 1569.69(a)(2) and submit a signed declaration of understanding to LPA by POC due date .
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:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
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