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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052700992
Report Date: 05/12/2026
Date Signed: 05/28/2026 10:08:09 PM

Document Has Been Signed on 05/28/2026 10:08 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/
DIRECTOR:		JACOB HARRYMANFACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY: 78CENSUS: 68DATE:
05/12/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Executive Director Shayan GheisarTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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A Noncompliance Conference (NCC) was conducted today on May, 12,2026, via Microsoft Teams. The purpose of the NCC was to discuss the complaints since licensure. Present at today’s NCC were the Sacramento South Regional Office Adult and Senior Staff, Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Lisa Rios, Licensing Program Analyst (LPA) Jason Lund. Present from Foothill Village Senior Living, Shayan Gheisar, Executive Director, Wyatt Mello, CEO, Andrea Hoffman, Director of Clinical, and Joel Goldman, Counsel.

The non-compliance conference process was explained during this meeting to include the administrative process.

The NCC is being held due to non-compliance. Since facility licensure on 5/18/2021 the facility has a total of 9 complaints, with 2 case management with Deficiencies visits. The facility has had 5 Type A citations with 3 under appeal and 7 Type B citations.

The deficiencies noted are:

Deficiencies: Incidental and Medical, Reporting Requirements, Managed Incontinence, Basic Services Requirements, Personal Rights, Personnel Requirements, Resident Records, Infection Control, Care of Persons with Dementia, Buildings and Grounds, Care and Supervision, and Food Service.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Jason Lund
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992
VISIT DATE: 05/12/2026
NARRATIVE
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Issues discussed during the Non-Compliance Conference were:

· Personal Rights of Residents


· Administrator- Qualifications and Duties
· Emergency Disaster Plan
· Building and Grounds
The facility has stated they will do the following to achieve continued and substantial compliance:
· Licensee will conduct inspections of all resident rooms to ensure all non-surge protected multi-plut outlet extenders are removed from resident rooms.
· Licensee will conduct inspections of all resident rooms to ensure all space heaters are removed from resident rooms.
· Licensee will develop an emergency disaster plan that includes procedures for assistive medical devices for oxygen equipment.
· Facility staff will email CCLD facility plans to achieve compliance by 05/22/2026 5:00 PM. In addition, all requested above documents shall be emailed to CCLD by 05/22/2026 5:00 PM. The department has requested documents regarding the new administrator the following documents: A letter from the licensee and/or Board appointing the individual as the Administrator.
· LIC308
· Copy of your current Administrator Certificate
· Any documentation that meets the education and/or experience requirements, if applicable
· A check of guardian/LIS is conducted to ensure the appointed individual is fingerprinted and associated to the facility.
· LIC 200 signed by the licensee or designee.
· LIC 500 to indicate the days/hours the Administrator is in the facility.
· LIC 501 so that we can determine if the Administrator meets the education / experience requirement.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Jason Lund
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
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: FOOTHILL VILLAGE SENIOR LIVING
FACILITY NUMBER: 052700992
VISIT DATE: 05/12/2026
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In addition, at this meeting the notified Licensee/Administrator was advised future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and further potential administrative action.

Community Care Licensing Department (CCLD) will do the following:

· Increase Monitoring to quarterly visits.


· TSP
Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited during this visit. An exit interview was conducted and copy of this report was provided via email and an electronic email receipt confirms receiving these documents.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Jason Lund
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC809 (FAS) - (06/04)
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