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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317817
Report Date: 08/14/2023
Date Signed: 08/18/2023 02:18:17 PM


Document Has Been Signed on 08/18/2023 02:18 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CLEGG CARE FACILITYFACILITY NUMBER:
340317817
ADMINISTRATOR:CLEGG, EDNA SFACILITY TYPE:
740
ADDRESS:7249 CARMI STREETTELEPHONE:
(916) 429-6444
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:10CENSUS: DATE:
08/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Edna CleggTIME COMPLETED:
02:30 PM
NARRATIVE
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On 08/18/2023 at 2:00 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to conduct a case management visit. LPA Lee met with licensee/administrator Edna Clagg and explained the purpose of the visit.

The purpose of today's visit, is in response to a learned deficiencies from a complaint investigation control number: 27-AS-20230710165633. It was learned that resident 1 (R1) was admitted to the hospital on 07/13/2023 and at the time of discharge (R1) was not accepted back to the facility. It was also learned that the facility did not provide (R1) a 30 day eviction letter and or notice. On 07/18/2023 during a complaint investigation, LPA Lee had advised Licensee/administrator that the best and right thing to do was to accept resident back into the facility and then issued resident the 30 day eviction. As a result, the facility did not follow eviction procedures and admission agreement.

The following deficiencies were observed and cited form California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of this LIC 809 report and appeal rights were given to licensee/administrator, Edna Clegg.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023
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 08/18/2023 02:18 PM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: CLEGG CARE FACILITY
FACILITY NUMBER: 340317817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2023
Section Cited
CCR
87224(a)

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87224(a) Eviction Procedures: the licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...This requirement was not met as evidence by:
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Licensee agrees to: review eviction regulations by POC date 08/25/2023. Licensee will email LPA a written statement stating eviction regulations have been reviewed and understood and email to LPA Lee by POC date08/25/2023 by 5:00 PM by end of day
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based on file review and interviews, the Licensee did not ensure to provide R1 or their responsible party a 30-day eviction letter and/or notice. This posed a potential health and safety risk to R1.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023
LIC809 (FAS) - (06/04)
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