<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005513
Report Date: 03/12/2024
Date Signed: 03/12/2024 10:33:04 AM


Document Has Been Signed on 03/12/2024 10:33 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:STERLING COURT AT ROSEVILLEFACILITY NUMBER:
317005513
ADMINISTRATOR:CONDIE, NATHANFACILITY TYPE:
740
ADDRESS:100 STERLING CTTELEPHONE:
(916) 786-7200
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:128CENSUS: 76DATE:
03/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator, Sheri Kimbro TIME COMPLETED:
10:40 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 03/12/24 to conduct a case management to follow up on a recent AWOL at the facility. LPA met with facility Administrator Sheri Kimbro and explained the purpose of the visit.

The facility submitted a completed Unusual Incident/Injury Report (LIC624) on/around 03/05/24 regarding resident (R1) leaving the facility unattended on 03/04/24, at approximately 2:45 pm. R1 was found by staff who worked at another licensed facility down the street around 3pm and brought back to the facility uninjured by staff. IR stated that R1 was coming back to the memory care unit around 2:45pm after attending an activity in the assisted living unit in the facility and got AWOL as facility staff did not assist R1 safely back to memory care unit and did not do the head count of all residents properly. Facility notified CCLD, R1s physician, responsible party regarding this incident on 03/05/24 as required.

R1's physician's report, dated 07/25/23, indicates that resident has diagnosis of Mild Cognitive Impairment (MCI)/Dementia and cannot leave the facility unassisted. Although no injuries resulted from R1’s AWOL, R1 was unable to leave the facility unassisted. Facility staff did not provide care and supervision to R1 resulting in R1 leaving the facility unassisted therefore violations are cited today per California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies issued are noted on the LIC809D.

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



SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
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 03/12/2024 10:33 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: STERLING COURT AT ROSEVILLE
FACILITY NUMBER: 317005513

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2024
Section Cited
CCR
87705(c)(4)

1
2
3
4
5
6
7
87705- Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Current Licensee/Administrator conducted staff training on keeping a closer watch on any residents that may have a tendency for wondering behavior (AWOL) and document any changes in condition. Documentation of training should be sent to department by POC date- 03/13/24.
8
9
10
11
12
13
14
Based on interviews conducted and record review, facility staff did not provide care and supervision to R1 resulting in R1 leaving the facility unassisted on 03/04/24 which posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2