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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920034
Report Date: 09/05/2024
Date Signed: 09/05/2024 06:14:47 PM


Document Has Been Signed on 09/05/2024 06:14 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:VITAE HOME CAREFACILITY NUMBER:
315920034
ADMINISTRATOR:ANJANA KUMARIFACILITY TYPE:
740
ADDRESS:6882 BRANDY CIRCLETELEPHONE:
(916) 797-6238
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:6CENSUS: 5DATE:
09/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Anjana KumariTIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 9/5/24 to conduct a Pre-licensing Inspection utilizing the CARE tool. LPA Met with the applicant/ Administrator.

During the inspection it was found through interviews that the licensee transferred responsibility to the applicant for payment of the licensee's phone/ internet service, annual licensing fees and liability insurance between March 2024 to today.

In March, after licensee sold the business, the licensee discontinued phone/internet service to the home resulting in an approximate 4 day disruption to residents.

Additionally, regulations require the licensee maintain liability insurance for their facility. By transferring the policy to another party other that the licensee, this license was not properly insured.

As a result of this visit, deficiencies are cited.

The report was reviewed, copy provided and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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 09/05/2024 06:14 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: VITAE HOME CARE
FACILITY NUMBER: 315920034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2024
Section Cited
CCR
87311

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Telephones - All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility. This requirent was not met based on interviews. This posed a potential risk to residents.
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This citation is cleared during the visit as the applicant for the change of ownership reinstated phone service for the residents after the licensee lapsed.
Type B
09/06/2024
Section Cited
CCR
1569.605

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Liability insurance; coverage requirements- ...all residential care facilities for the elderly,..., shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate
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This citation is cleared during the visit as the applicant for the change of ownership took over the payment of a policy for this location.
As the applicant will receive a new license and this license will be terminated, no further action in required.
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This requirement was not met based on interview and record that found that the licensee failed to maintain the required insurance between March 2024 to present.
This posed a potential risk to the resident.
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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: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2