<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052700992
Report Date: 01/03/2024
Date Signed: 01/03/2024 04:52:53 PM


Document Has Been Signed on 01/03/2024 04:52 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:FOOTHILL VILLAGE SENIOR LIVINGFACILITY NUMBER:
052700992
ADMINISTRATOR:MARY MCCLUREFACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY:78CENSUS: DATE:
01/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Angelica WhiteTIME COMPLETED:
05:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 1/3/24 LPA Jensen conducted an unannounced visit to continue a complaint investigation in to complaint control number 27-AS-20231122163414. LPA Jensen observed a deficiency while conducting the complaint investigation and conducted a case management to address the concern. LPA Jensen met with Resident Care Director Angelica White and explained the purpose of the visit.

While reviewing records for complaint control number 27-AS-20231122163414 LPA Jensen reviewed an admission agreement for Resident 1 (R1). The admission agreement states that under Part C - Change of Service Plan, on page 13:
...We will preform regular Resident Assessments of your needs. If we determine , in consultation with you, your family and/or your physician, that you need a modification of the service plan that you are currently receiving at Foothill Village, and we provide this service, you agree to change to a level of service that is appropriate to your needs. The rates for services, as set forth in Appendix A, shall apply immediately.

LPA Jensen reviewed Appendix A and observed no rates to be set forth. Section II - Schedule of Care Fees is crossed out and no monetary values are listed.

Deficiencies are being cited pursuant to the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in the assessment of Civil Penalties.

An exit interview was conducted and a copy of this report and appeal rights were given
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024
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 2


Document Has Been Signed on 01/03/2024 04:52 PM - It Cannot Be Edited

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: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2024
Section Cited
CCR
87507(g)(B)(1)

1
2
3
4
5
6
7
Admission Agreements
Rate for additional items and services, including:
A comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed.
1
2
3
4
5
6
7
The Licensee or facility staff shall submit a plan for approval by the POC due date, to LPA Jensen, that describes actions that will be taken to audit admission agreements and bring them in to compliance.
8
9
10
11
12
13
14
This requirement was not met as evidenced by LPA Jensen's review of an admission agreement for R1 that references a fee schedule in Appendix A that was missing or non-existent. This poses a potential risk to the health, safety and personal rights of residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2