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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340308207
Report Date: 04/08/2024
Date Signed: 04/08/2024 11:26:38 AM

Document Has Been Signed on 04/08/2024 11:26 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/
DIRECTOR:		MANGABAT, NORMINIOFACILITY TYPE:
740
ADDRESS:2715 G ST.TELEPHONE:
(916) 447-1502
CITY:SACRAMENTOSTATE: CAZIP CODE:
95816
CAPACITY: 13CENSUS: 11DATE:
04/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Gladys MangabatTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to open a complaint investigation. During the course of this investigation, LPA Moleski observed unrelated deficiencies. LPA Moleski met with facility administrator Gladys Mangabat and explained the purpose of the visit.

While touring this facility, LPA Moleski and Mangabat observed Tylenol unsecured in a resident's room. LPA Moleski and Mangabat observed a cleaning product containing bleach left unsecured in a cabinet in a resident bathroom.

This facility is being cited per 22 CCR Sections 87309(a) and 87465(h)(2). An exit interview was held with Mangabat. Appeal rights and a copy of this report were left with Mangabat.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
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 04/08/2024 11:26 AM - It Cannot Be Edited


Created By: Vincent Moleski On 04/08/2024 at 11:00 AM
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: 04/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2024
Section Cited
CCR
87309(a)

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"(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients."
This requirement was not met as evidenced by:
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Licensee removed the cleaner during this visit. LPA Moleski shall return to reassess compliance.
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Based on observation, a cleaning solution was accessible to residents, which poses an immediate health and safety risk.
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Type A
04/09/2024
Section Cited
CCR87465(h)(2)

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"(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication."
This requirement was not met as evidenced by:
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Licensee removed the medication during this visit. LPA Moleski shall return to reassess compliance.
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Based on observation, medication was accessible to a resident, which poses an immediate health and safety 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 Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024


LIC809 (FAS) - (06/04)
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