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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340308207
Report Date: 07/15/2024
Date Signed: 07/15/2024 11:35:02 AM


Document Has Been Signed on 07/15/2024 11:35 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SACRAMENTO GUEST HOMEFACILITY NUMBER:
340308207
ADMINISTRATOR:MANGABAT, NORMINIOFACILITY TYPE:
740
ADDRESS:2715 G ST.TELEPHONE:
(916) 447-1502
CITY:SACRAMENTOSTATE: CAZIP CODE:
95816
CAPACITY:13CENSUS: 12DATE:
07/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gladys MangabatTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to open a complaint investigation. LPAs Moleski and Williams met with licensee Gladys Mangabat and explained the purpose of the visit.

LPAs Moleski and Williams investigated a complaint regarding measures taken to address a bed bug infestation. Mangabat had been aware of the infestation since at least June 11, 2024, based on a contract signed by her and a representative of a pest control company. Mangabat verbally acknowledged the infestation and said she had not sent in an incident report to the Community Care Licensing Division. LPAs Moleski and Williams received no incident reports regarding this infestation.

This facility is hereby cited per 22 CCR Section 87211(a)(1)(D). An exit interview was held with Mangabat. Appeal rights and a copy of this report were left with Mangabat.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
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 07/15/2024 11:35 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: SACRAMENTO GUEST HOME
FACILITY NUMBER: 340308207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2024
Section Cited
CCR
87211(a)(1)(D)

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"(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:..
(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." This requirement was not met as evidenced by:
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Licensee agrees to send LPA Moleski an incident report, and to review the applicable 22 CCR sections regarding reporting requirements, and to send LPA Moleski a signed statement acknowledging these requirements by POC due date.
vincent.moleski@dss.ca.gov
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Based on interviews, observation, and record review, an incident report was not sent in after an outbreak of bed bugs at this facility, which poses a potential health, safety, and/or personal rights risk.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
LIC809 (FAS) - (06/04)
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