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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340308207
Report Date: 09/19/2025
Date Signed: 09/19/2025 03:24:06 PM

Document Has Been Signed on 09/19/2025 03:24 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SACRAMENTO GUEST HOMEFACILITY NUMBER:
340308207
ADMINISTRATOR/
DIRECTOR:		MANGABAT, NORMINIOFACILITY TYPE:
740
ADDRESS:2715 G ST.TELEPHONE:
(916) 447-1502
CITY:SACRAMENTOSTATE: CAZIP CODE:
95816
CAPACITY: 13CENSUS: 11DATE:
09/19/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Gladys MangabatTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 9/19/25 Licensing Program Analyst (LPA) Kevin Gould conducted a Case Management Deficiencies inspection to address deficiencies observed during a complaint investigation.

LPA determined that the facility is not reporting incidents as required by the department that would pose a health and safety risk to residents. LPA determined through interviews that there have been several incidents where R1 is leaving the facility without informing staff members and attempting to steal mail from neighbors, breaking into a neighbors vehicle, attempting to enter neighbors homes. The department has received no incident reports for any of the above incidents.

LPA also determined an eviction notice provided to R1 did not meet department requirements and was not sent to the department within 5 days of issuance which again does not meet regulations. Additionally, upon LPA's arrival to the facility today, LPA observed the front and back doors to be open, LPA knocked and announced his presence at the facility several times. LPA encountered a resident who directed LPA to a staff bedroom where the staff member was in the bedroom with the door closed not proving supervision to residents.

Per the California Code of Regulations, Title 22, the following deficiencies are cited during today's inspection.
Exit interview conducted and a copy of this report and appeal rights are left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Kevin Gould
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/19/2025 03:24 PM - It Cannot Be Edited


Created By: Kevin Gould On 09/19/2025 at 02:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SACRAMENTO GUEST HOME
FACILITY NUMBER: 340308207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2025
Section Cited
CCR
87224(f)87224(f)

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Eviction Procedures: A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by LPA has not received any notification of eviction for resident within 5 days of issuing the eviction to resident which
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Licensee was issued a copy of eviction procedures. and agreed to resubmit an eviction notice that meets all requirements by the POC due date.
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poses a potential health, safety and personal rights risk to residents in care.
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Type B
09/26/2025
Section Cited
CCR87211(a)(1)(D)

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Reporting Requirements: 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 several incidents of resident exiting the
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Licensee has agreed to submit incident reports for all incidents identified for resident which is required to be reported to the department by the POC due date.
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facility and attempting to steal mail, break into cars and enter the homes of nearby neighbors which poses a potential health, safety and personal rights risk to residents in care.
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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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Kevin Gould
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/19/2025 03:24 PM - It Cannot Be Edited


Created By: Kevin Gould On 09/19/2025 at 03:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SACRAMENTO GUEST HOME
FACILITY NUMBER: 340308207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2025
Section Cited
CCR
87464(f)(1)

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Basic Services: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by upon LPA's arrival to the facility today, LPA observed the front and back doors to be open, LPA knocked and
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Licensee has agreed to submit a written plan of correction detailing the steps facility will take to ensure staff are always present and not in their rooms with the door closed to ensure residents received the care and supervision needed at the facility.
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 announced his presence at the facility several times. LPA encountered a resident who directed LPA to a staff bedroom where the staff member was in the bedroom with the door closed not proving supervision to residents which poses a potential health, safety and personal rights risk to residents.
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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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Kevin Gould
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2025


LIC809 (FAS) - (06/04)
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