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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920034
Report Date: 06/11/2024
Date Signed: 06/11/2024 11:47:50 AM


Document Has Been Signed on 06/11/2024 11:47 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:VITAE HOME CAREFACILITY NUMBER:
315920034
ADMINISTRATOR:IRYNA OMELIANFACILITY TYPE:
740
ADDRESS:6882 BRANDY CIRCLETELEPHONE:
(916) 797-6238
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:6CENSUS: 5DATE:
06/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:ANJANA KUMARI TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday June 11, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (1) and staff files (1).

Due to time constraints, LPA Parks will return at a later date to complete the annual inspection.

See 809-D for deficiency cited during todays visit.

Exit interview conducted. A copy of this report along with appeal rights were emailed to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
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 06/11/2024 11:47 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: VITAE HOME CARE
FACILITY NUMBER: 315920034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

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 1 out of 1 file reviewed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2024
Plan of Correction
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Administrator submitted a fingerprint transfer request to the RO while LPA was at the facility. The citation was cleared on cite.
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: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2