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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097000177
Report Date: 02/14/2024
Date Signed: 02/14/2024 11:52:13 AM


Document Has Been Signed on 02/14/2024 11:52 AM - 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:LARC'S CARE HOMEFACILITY NUMBER:
097000177
ADMINISTRATOR:SUSBILLA, CORAZON R.FACILITY TYPE:
740
ADDRESS:3488 LA CANADA DRIVETELEPHONE:
(530) 677-6724
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:6CENSUS: 5DATE:
02/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Corazon SusbillaTIME COMPLETED:
12:00 PM
NARRATIVE
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During the complaint (#59-AS-20240207154557) investigation visit on 02/14/24, Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan, met with Administrator Corazon Susbilla. It was discovered, from record review for Resident, R1 that Licensee/Administrator Corazon Susbilla, was the Power of Attorney (POA) for R1, which is a violation of CCR regulation under Title 22 ,87217 (d)(2) which state that no licensee or employee of a facility shall accept any general or special power of attorney for any residents.

Based on record review and interviews with R1 and staff, S1, it has been revealed that S1 was the appointed POA for R1 which was a violation of above regulation. Based on this information, per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is cited on the attached 809-D page.

Exit interview conducted with administrator. Copy of the report and appeal rights provided.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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 02/14/2024 11:52 AM - 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: LARC'S CARE HOME
FACILITY NUMBER: 097000177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2024
Section Cited
CCR
87217(d)(2)

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 87217- Safeguards for Resident Cash, Personal Property, and Valuables-
(d) Except as provided in approved continuing care agreements, no licensee or employee of a facility shall:(2) accept any general or special power of attorney for any such person;This requirement is not met as evidenced by;
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Licensee/administrator shall submit proof to CCLD that they are no longer the POA for R1 including documentation who will be the POA for R1.
POC documents are due by 02/28/24.
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Based on records review and interviews, it has been concluded that administrator, S1, signed legal power of attorney (POA) for resident, R1 on 12/06/2023 which is a violation of above regulation and poses a potential health and safety risks to residents in care.
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Civil Penalties shall be assessed if POC requirement is not met by due date, 02/28/24.

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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2