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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002983
Report Date: 10/24/2024
Date Signed: 11/11/2024 05:20:50 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/11/2024 05:20 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:COUNTRY PALMS CARE HOMEFACILITY NUMBER:
397002983
ADMINISTRATOR/
DIRECTOR:		TRIPLETT, JOSEPH J.FACILITY TYPE:
740
ADDRESS:2905 BRISTOL AVENUETELEPHONE:
(209) 462-1135
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 6CENSUS: 4DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Belle and TeresaTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 122.9 degrees Fahrenheit in resident bathroom sink, which is not within the required range of 105 to 120 degrees.

Fire extinguishers and carbon monoxide detectors are operational. LPA observed centrally stored medications are kept locked, however the hinges need to be replaced. (Advisory given)

LPA reviewed and compared resident medication vs. resident medication logs. The facility used the wrong date packet of medication. The date of the packet started was 10/27/2024. The facility has the right dated medication for the week however, they used the wrong one. The medication are the same, but the start dates are wrong. (Advisory given)
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COUNTRY PALMS CARE HOME
FACILITY NUMBER: 397002983
VISIT DATE: 10/24/2024
NARRATIVE
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 LPA reviewed 4 resident and 2 staff files, including criminal record clearances. During the file review LPA observed during the staff file review an expired first aid/CPR card for S1 and an expired ID for S1 as well.

All staff are fingerprinted and cleared. First aid kit was checked and is complete.

Deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/11/2024 05:20 PM - It Cannot Be Edited


Created By: Albert Johnson On 10/24/2024 at 02:34 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: COUNTRY PALMS CARE HOME
FACILITY NUMBER: 397002983

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2024
Section Cited
CCR
87303(e)(2)

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(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
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The facility will adjust the water temperature today to the required temperature. The facility will conduct water temperature logs for one week to ensure the hot water temperature is within regulations and the hot water is properly circulated throughout the facility.
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Based on LP'As testing of water temperatures in residents bathroom, LPA recorded temperatures of 122.5 degrees respectively the licensee did not comply with the section cited above in as the water temperature was not inside the approved approved varience of 105 to 120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
10/31/2024
Section Cited
CCR87411(c)(1)

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(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
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Administrator shall call the first aid vendor and requested a New Card or send by email proof. Administrator will send a copy of First Aid card to LPA. FAX (916) 263-4744
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This requirement is not met as evidenced by record review S1 has an expired first aid/CPR card. This poses a potential risk to 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:Lisa Rios
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


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