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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397000839
Report Date: 10/03/2023
Date Signed: 10/03/2023 04:18:14 PM

Document Has Been Signed on 10/03/2023 04:18 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MARY FRANCES HAT RESIDENTIAL FACILITYFACILITY NUMBER:
397000839
ADMINISTRATOR:LAURA REEVESFACILITY TYPE:
740
ADDRESS:14381 E. SARGENT ROADTELEPHONE:
(209) 334-6454
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 6CENSUS: 3DATE:
10/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Laura Reeves, AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct a case management visit on 10/03/23. LPA Campbell obtained information that the resident had resided in the home with a stage 3 pressure wound without an exception request.

The Department conducted interviews, reviewed documentation submitted and determined that the resident had a Stage Three Pressure Wound after leaving the hospital on 06/16/2023. Based on interviews with administrator Laura Reeves, the resident was admitted back to the facility despite having no approved exception request from the Department. Licensing was not notified of the prohibited health condition and no exception request was received by licensing.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit.

If any of the cited deficiencies are not corrected by the noted due dates, civil penalties may be assessed. The Facility Designee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted, a copy of the report was given.

SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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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Document Has Been Signed on 10/03/2023 04:18 PM - It Cannot Be Edited


Created By: Renee Campbell On 10/03/2023 at 03:57 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: MARY FRANCES HAT RESIDENTIAL FACILITY
FACILITY NUMBER: 397000839

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2023
Section Cited
CCR
87615(a)(1)

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Prohibited Health Conditions -Persons who require health services for or have a health condition including but not limited to, those specified below, shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement is not met as evidence by:
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POC
The licensee shall train all staff on prohibited health conditions and submit a signed attendance roster of all employees that were educated on the regulation along with a statement of understanding to LPA by POC due date of 10/13/2023.
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Based on LPA Campbell’s observation of file reviews for R1 and Adventist Home Health Nurse’s statement that R1 had a Stage Three Pressure Wound while in the facility for more than 24 hrs. This poses an immediate risk to the health, safety and personal rights of residents in care.
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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:Emerita Curiel
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


LIC809 (FAS) - (06/04)
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