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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701275
Report Date: 06/12/2024
Date Signed: 06/24/2024 12:19:13 PM

Document Has Been Signed on 06/24/2024 12:19 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BEATITUDES CARE HOME IFACILITY NUMBER:
392701275
ADMINISTRATOR/
DIRECTOR:		NOLASCO, RICKY C.FACILITY TYPE:
740
ADDRESS:925 CLEARWATER CREEK BLVDTELEPHONE:
(209) 647-9701
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 6CENSUS: 5DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Ricky NolascoTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 06/12/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff persons, Rosalinda Wright and Ivania Lopez, who were briefly interviewed.
This LPA requested that the facility staff go ahead and contact the facility designated Administrator, Ricky Nolasco, to inform him that CCL was present at this time.
Current census was 5 residents.
It was learned that there were not any residents under the care of hospice at this time.
It was learned that there were not any residents receiving services through home health at this time.
It was learned that there weren't any residents diagnosed with dementia at this time.
The facility designated Administrator, Ricky Nolasco, arrived later to this facility while this LPA was conducting this annual visit. Facility staff files were supplied by the facility designated Administrator. This LPA requested for all (3) facility staff files at this time.
Tour of this facility was conducted.
Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Linen closet, located in facility hallway, was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time.
Kitchen area was toured.
Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times.
Additional food storage units were observed to be present and functional at this time.
Laundry area was toured. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Administrator certificate, #6057310740, for Ricky Nolasco was observed to have an expiration date of 09/28/2024 and in compliance at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BEATITUDES CARE HOME I
FACILITY NUMBER: 392701275
VISIT DATE: 06/12/2024
NARRATIVE
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Medication cabinet, located in the facility kitchen cabinets, was observed to be locked and made inaccessible to the residents at this time.
First aid kit, located in a kitchen drawer, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguisher, located under the kitchen sink, was observed to have been annually inspected by the local fire extinguisher company and purchased on 09/01/2023 and in compliance at this time.
Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted.
A review of (5) facility resident files was conducted and noted on the following LIC 858.
A review of (3) facility staff files was conducted and noted on the following LIC 859.
The following forms and documents were requested to be updated and submitted into CCL:
  • 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 Codes.

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: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/24/2024 12:19 PM - It Cannot Be Edited


Created By: Charlie Yang On 06/12/2024 at 12:41 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: BEATITUDES CARE HOME I
FACILITY NUMBER: 392701275

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

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 in that the hot water measured in the resident restrooms were at 122.4 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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The facility designated Administrator stated that the hot water heater will be turned down and the hot water will be measured to make sure that it is within the allowed range of 105-120 degrees at all times. A statement of correction, along with readings for the hot water temperatures taken for at least (7) days, will be completed and submitted into CCL by the due date.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 [2] out of [3] staff files did not contain updated First Aid Training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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The facility designated Administrator stated that all staff providing care and supervision to the residents in care will be scheduled for First Aid Training and complete it as well. A statement of correction, along with copies of all updated First Aid Training for each staff person, will be completed and submitted into CCL by the 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:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/24/2024 12:19 PM - It Cannot Be Edited


Created By: Charlie Yang On 06/12/2024 at 12:41 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: BEATITUDES CARE HOME I
FACILITY NUMBER: 392701275

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 in that several drawers throughout this facility in the kitchen and restroom area were broken and in need of repair. In addition, the side gate latch was broken and unable to latch properly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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The facility designated Administrator stated that the broken drawers will be repaired/replaced as well as the broken side gate latch will be repaired/replaced so that the side gate will latch and close properly. A statement of correction, along with photos of all updated drawers and side gate latch, will be completed and submitted into CCL by the due date.
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 in that there were windows screens which had holes, tears, or cuts in them and were in need of repair/replacement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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The facility designated Administrator stated that the window screens will be repaired/replaced to make sure that there aren't any holes, tears, or cuts in them. A statement of correction, along with photos of all updated window screens, will be completed and submitted into CCL by the 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:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/24/2024 12:19 PM - It Cannot Be Edited


Created By: Charlie Yang On 06/12/2024 at 12:41 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: BEATITUDES CARE HOME I
FACILITY NUMBER: 392701275

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 [3] out of [3] facility staff files did not contain the required number of training hours which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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The facility designated Administrator stated that all facility staff will undergo and receive the required annual number of training hours. A statement of correction, along with copies of completed training topics and hours, will be completed and submitted into CCL by the 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:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
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