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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700016
Report Date: 08/07/2026
Date Signed: 08/07/2026 01:54:23 PM

Document Has Been Signed on 08/07/2026 01:54 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:RESTPADD CARE LLCFACILITY NUMBER:
342700016
ADMINISTRATOR/
DIRECTOR:		NWANGBURUKA, IHEOMAFACILITY TYPE:
740
ADDRESS:6901 RIO TEJO WAYTELEPHONE:
(916) 685-3690
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 6DATE:
08/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Iheoma NwangburukaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On August 7, 2026, at approximately 10:20am, Licensing Program Analyst, Arvin Villanueva (LPA), arrived at this facility unannounced to conduct the annual inspection visit. LPA initially met with staff on duty, Mila Capacete (S1), and stated the purpose of the visit. The admistrator Iheoma Nwangburkuka (AD), was notified and arrived shortly after.
Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents, up to 6 may be non-ambulatory. Facility does not have clearance for bedridden, delayed egress, and locked exterior/interior. Facility has 2 fire doors.
Upon arrival: LPA observed the room temperature to be at 79 degrees Fahrenheit. Present were 6 residents in care with 1 staff on duty.
Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident units, resident bathrooms, dining room and outdoor areas.
LPA and AD inspected 4 of 5 resident bedrooms and 2 of 3 bathrooms. Hot water temperature was measured in the hallway bathroom was at 98.8 degrees Fahrenheit. Advisory provided to ensure the two fire doors remain closed at all times.
In the kitchen area, LPAs observed at least 7-day nonperishable and 2-day perishable food supplies. Knives/sharps and cleaning solutions were locked. Fire extinguishers observed and last serviced on 9/3/2025. Smoke detectors were observed throughout and at least one carbon monoxide detector was observed. Advisory provided to install additional carbon monoxide in the resident hallways due to the fire doors.
Medication cabinet was observed to be locked and not accessible to residents. During inspection of the medication cabinet, LPA observed a couple of days’ worth of medications pre-poured in a plastic pill case for each residents taking medication. Pre-pouring of medication more than 24 hours in advance is a violation of Title 22 regulations.
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Stephen Richardson
Arvin Villanueva
DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2026
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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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: RESTPADD CARE LLC
FACILITY NUMBER: 342700016
VISIT DATE: 08/07/2026
NARRATIVE
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The outdoor area was inspected. Regarding the fence, located at the garage side, part of it was observed to be leaning and advisory as provided to address this as soon as possible. Exit gate was observed to be in good repair. No bodies of water were present. The LPA observed a shaded area with furniture available for outdoor activities. An advisory was provided to the facility to ensure all staff are familiar with the location and operation of shut-off valves in case of an emergency. An additional advisory was issued regarding trimming or clearing vegetation along the side walkways to maintain safe access.
Record Reviews:
Review of 4 of 6 resident files was conducted, including but not limited to, review of Admission Agreement, Physician Reports, and Ambulatory Status. Advisory provided to ensure all residents have doctor’s assessment regarding their capacity to determine or communicate their need for PRN medication.
Review of 2 staff files included but not limited to background clearance, first aid/CPR certification, and training. Per review, staff on duty during this visit did not have a current First Aid certificate, only CPR certificate. Per AD, it is her oversight.
Facility do not have proper documentation for quarterly disaster drill. The documentation that was reviewed did not have the proper documentation. However, per AD, they conduct quarterly drills. Advisory provided to develop a drill log specific to disaster drills.
Interviews: 1 staff member and 1 resident in care.
Documents Requested: LPA requested a copy of updated Liability Insurance, Personnel Records (LIC500), and Designation of Facility Responsibility LIC308 to be emailed to arvin.villanueva@dss.ca.gov
Per the California Code of Regulations, Title 22, Division 6, Chapter 6 and Health and Safety Code deficiencies were cited. Advisories were provided.
Plan of Correction and Appeal Rights were discussed during exit interview with AD. A copy of the report and appeal rights were provided.
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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
LIC809 (FAS) - (06/04)
Page: 3 of 14
Document Has Been Signed on 08/07/2026 01:54 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 08/07/2026 at 01:00 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: RESTPADD CARE LLC
FACILITY NUMBER: 342700016

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Hot water was measured at 98 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2026
Plan of Correction
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Per discussion, administrator will start loging the hot water temperature readings daily for 7 days and submit the log by POC due date.
Per administrator, she will start loging the hot water temperature reading monthly after that.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview with administrator, the licensee did not comply with the section cited above. Staff are pre-pouring medications couple of days in advance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2026
Plan of Correction
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Administrator will submit to the Department by POC due date a written statement of understanding of the regulation relating to medication administration.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 08/07/2026 01:54 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 08/07/2026 at 01:45 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: RESTPADD CARE LLC
FACILITY NUMBER: 342700016

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above. Staff on duty did not have a current first aid certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2026
Plan of Correction
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Per administrator, she will submit a current first aid for staff by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2026


LIC809 (FAS) - (06/04)
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