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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004556
Report Date: 06/27/2024
Date Signed: 06/27/2024 01:05:54 PM

Document Has Been Signed on 06/27/2024 01:05 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:CASA DE LUZFACILITY NUMBER:
507004556
ADMINISTRATOR/
DIRECTOR:		JOHANNA WESTFACILITY TYPE:
740
ADDRESS:3509 SCENIC DRTELEPHONE:
(209) 578-3077
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 5DATE:
06/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Johanna West TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 06/27/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with saff member(SM), Terri Salcido and explained the purpose of the visit. LPA asked that SM Salcido call the Facility Designated Administrator (FDA), Johanna West that CCL was present at this time. Shortly after, LPA met with FDA West and explained the purpose of the visit.
This facility is licensed to serve up to 6 elderly residents. This facility does not currently have a dementia plan on file and does not have a hospice waiver.

LPA reviewed 5 resident files. 3 out 5 resident files did not have an updated and current medical assessment. LPA reviewed 4 staff files. 3 out 4 staff did not have a current First Aid/CPR certificate on file.
The FDA has a current administrator certificate #7025100740 and expires on 08/11/02025.
A tour was initiated with FDA West. Fire extinguisher was serviced by Jorgenson Co and is valid until 06/12/2024. Smoke alarms and carbon monoxide were in good repair.
A tour of the kitchen was conducted. LPA observed a sufficient amount of 7 day non-perishable food supply as well as 2 day perishable food supply in the main kitchen. Knives were observed to be locked and made inaccessible to the residents. Additional perishable food supply was identified in the garage.
LPA observed a locked centralized stored medication cabinet. Along with FDR Andrade, LPA reviewed and compared medication with medication dispensing logs.
LPA observed a locked cleaning supply cabinet. First aid kit was present and contained all the required components.
Living room area, dining room, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be in good repair and sufficient to meet resident needs at this time.
A tour of 3 resident bedrooms were conducted. Resident furniture was observed to be sufficient to meet their needs at this time.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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: CASA DE LUZ
FACILITY NUMBER: 507004556
VISIT DATE: 06/27/2024
NARRATIVE
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A tour of the resident bathrooms were conducted. Hot water temperature was within the required range of 105-120 degrees. Grab bars were present.

Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.

A tour of the exterior physical plant was conducted. Perimeter fence, side gates, and exits was inspected.

The following forms and documents were requested to be updated and submitted into CCL:
-LIC 308

-LIC 400

-LIC 500

-LIC 610

-Liability insurance

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

Exit Interview was conducted, a copy of this report and appeals rights were provided to the Facility at the end of this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/27/2024 01:05 PM - It Cannot Be Edited


Created By: Arielle Pascua On 06/27/2024 at 12:08 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: CASA DE LUZ
FACILITY NUMBER: 507004556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not obtaining First Aid certification for 2 staff members. 2 out 4 staff members first aid was observed to be expired and out of compliance. This poses a immediate health, safety and personal rights risks to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Licensee agrees to provide a written statement to LPA that states that they have read the regulation to it's entirety by POC date. In addition, Licensee agrees to provide a copy of First Aid training and certificates to the LPA's email. arielle.pascua@dss.ca.gov
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:Lisa Rios
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


LIC809 (FAS) - (06/04)
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