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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315003019
Report Date: 07/02/2024
Date Signed: 07/02/2024 03:37:54 PM


Document Has Been Signed on 07/02/2024 03:37 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:A1 SENIOR CARE 3FACILITY NUMBER:
315003019
ADMINISTRATOR:PACATANG, BARBRAFACILITY TYPE:
740
ADDRESS:421 ASHWOOD WAYTELEPHONE:
(279) 336-1702
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 6DATE:
07/02/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Barbra PacatangTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday July 2, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (6) and staff files (2). All resident files contained the required paperwork. Staff files contained the required training. Staff files did not contain proof of required first aid/cpr.

LPA Parks and Administrator Barbra toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, living room, kitchen, and garage. In the areas toured, there were no health or safety violations observed.

Facility was clean and well organized. All required posting were observed. All knives/sharps are kept locked and inaccessible to residents. First Aid kit was fully stocked.

See 809-D for deficiency. Appeal rights were given. Exit interview conducted. A copy of this report was emailed to the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
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 07/02/2024 03:37 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: A1 SENIOR CARE 3
FACILITY NUMBER: 315003019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 0 out of 2 files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2024
Plan of Correction
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Administrator agrees to proof of completed first aid/cpr for S1 and S2
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2