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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701344
Report Date: 07/15/2024
Date Signed: 07/16/2024 10:10:39 AM

Document Has Been Signed on 07/16/2024 10:10 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DANICA'S HOMEFACILITY NUMBER:
392701344
ADMINISTRATOR/
DIRECTOR:		FLORES, OLIVERFACILITY TYPE:
740
ADDRESS:1746 TANAGER AVETELEPHONE:
(510) 584-1787
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 6CENSUS: 1DATE:
07/15/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Oliver FloresTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Unannounced Post Licensing visit made out to this facility on 07/15/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, Oliver Flores, who was briefly interviewed at this time.
Current census was 1 resident.
It was learned that there weren't any residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (6) residents under the care of hospice at any given time.
It was learned that this facility has a program to be able to accept and retain dementia residents at any given time. It was learned that there weren't any residents diagnosed with dementia at this time.
It was learned that there was (1) resident receiving services through home health 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 entryway, 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.
Laundry area, located in the facility hallway leading into the garage 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, #6065720740, for Oliver Flores was observed to have an expiration date of 01/18/2025 and in compliance at this time.
Medication cabinet, located in the facility kitchen area, was observed to be locked and made inaccessible to the residents at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DANICA'S HOME
FACILITY NUMBER: 392701344
VISIT DATE: 07/15/2024
NARRATIVE
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First aid kit, located adjacent to the kitchen area, was reviewed. This LPA observed that it did contain all of the required components at this time.
Fire extinguisher, located in the facility entryway hallway, was observed to have been annually purchased on 09/16/2023 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. This LPA observed additional storage sheds that were present on the east side of this facility at this time. The storage sheds were observed to be locked and made inaccessible to the residents at this time.
A review of (2) facility personnel records was conducted and noted on the following LIC 859.
A review of (1) facility resident record was conducted and noted on the following LIC 858.

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: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/16/2024 10:10 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/15/2024 at 12:24 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: DANICA'S HOME
FACILITY NUMBER: 392701344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 [1] out of [2] facility personnel records did not possess an updated and documented TB clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2024
Plan of Correction
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The facility designated Administrator stated that all facility resident records will be updated to contain updated TB clearances at all times. A statement of correction, along with updated copies of the cleared TB clearance, will be completed and submitted into CCL by the due date of 07/16/2024.

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: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/16/2024 10:10 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/15/2024 at 12:24 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: DANICA'S HOME
FACILITY NUMBER: 392701344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(b)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following:

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 [1] out of [2] facility resident files did not contain all of the required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2024
Plan of Correction
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The facility designated Administrator stated that all facility resident records will be updated to contain all of the required forms and documents at all times. A statement of correction, along with updated copies of the facility staff files, will be completed and submitted into CCL by the due date of 07/22/2024.
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 [2] out of [2] facility staff files did not contain the required hours of documented initial/ongoing training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2024
Plan of Correction
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The facility designated Administrator stated that all facility resident records will be updated to contain all of the required hours of initial/ongoing training at all times. A statement of correction, along with updated copies of the facility staff training hours, will be completed and submitted into CCL by the due date of 07/22/2024.
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: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/16/2024 10:10 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/15/2024 at 12:24 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: DANICA'S HOME
FACILITY NUMBER: 392701344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(h)(2)
Planned Activities
(h) Facilities shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas which are easily accessible to residents and protected from traffic. Gardens or yards shall be sufficient in size, comfortable, and appropriately equipped for outdoor use.

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 outdoor space intended for resident use needed to be cleared and cleaned to remove clutter and signs of dog use which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2024
Plan of Correction
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The facility designated Administrator stated that the exterior grounds of this facility will be cleared and cleaned to remove unnecessary items so that pathways and walkways were always clear for resident use. In addition, dog feces and toys will be removed to make sure that these areas were always clean and clear at all times. A statement of correction, along with photos of clean and clear backyard area, will be completed and submitted into CCL by the due date of 07/22/2024.
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: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024


LIC809 (FAS) - (06/04)
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