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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005513
Report Date: 09/18/2024
Date Signed: 09/18/2024 11:48:14 AM


Document Has Been Signed on 09/18/2024 11:48 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: 77DATE:
09/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator, Sheri Kimbro TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 09/18/24 to do case management visit for Resident, R1 for their AWOL incident for 08/28/24. LPA met with administrator Sheri Kimbro and explained the purpose of the visit.

The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 08/29/24 regarding resident (R1) leaving the facility unattended on 08/28/24, at approximately 6:45PM. It was reported that on 08/28/24, approximately 6:45pm when the med tech went to give resident, R1 their medications, R1 was not in their room. Around the same time, the concierge realized R1 had left their keys at the front desk, prompting a search for them inside the community, The search was extended to outside and R1 was located one street over by facility by staff at approximately 7:15pm. R1 was escorted back to the community by staff . R1 had a small cut on his forehead but didn't recall how they got it. EMTs were called and R1 was sent to local hospital for medical treatment. Facility notified R1s doctor and family regarding this AWOL incident.

Record review for R1 indicated that R1 got admitted on 08/24/24 to facility. R1s ,LIC602 signed by their physician on 08/21/24, indicated that R1 cannot leave facility unassisted.

The facility has been continuously implementing measures to prevent the AWOL incidents from occurring in the future to ensure the health and safety of residents in care.

Citations were issued per Title 22 Regulations as listed on LIC809-D. Civil penalties may be assessed if facility does not comply with POC requirements as indicated on LIC809-D. Exit interview conducted. Copy of report and appeal rights were provided to facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/18/2024 11:48 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: 09/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2024
Section Cited
CCR
80078(a)

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80078(a) -Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:
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Administrator agrees to hold a training on the AWOL procedure with all staff and send a copy of topics covered and a list of attendees name/date/signature by POC date, 09/19/24 and shall provide staffing as necessary to meet residents needs.
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Based off of observation and record reviews ,it has been concluded that resident, R1 AWOL'd from the facility on 08/28/24 due to lack of care and supervision of staff which presents an immediate health and safety risk to the resident in care.
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Facility agrees to revisit AWOL procedure and to submit in a written AWOL procedure to CCL within 15 days.

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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: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
LIC809 (FAS) - (06/04)
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