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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700029
Report Date: 08/04/2022
Date Signed: 08/04/2022 09:58:25 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/04/2022 09:58 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:CALI CARE RETIREMENT HOMEFACILITY NUMBER:
342700029
ADMINISTRATOR:MOJICA, CYNTHIAFACILITY TYPE:
740
ADDRESS:3630 WEST WAYTELEPHONE:
(916) 484-3027
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 5DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Emmanuel A Mojica TIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection on 08/02/2022. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyard of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for five non-ambulatory residents and 1 bedridden resident. There are currently 5 residents who reside at this facility. There is one resident on hospice.

The LPA toured the facility with Theresa Mata on 08/24/2021 at 8:50 AM.

The facility is sanitary and clean, and the furniture is spaced 6 feet apart. The facility has a seven day food supply. Resident bedrooms are sanitary and furnished. The facility bathrooms are sanitary. The facility smoke detectors, carbon detector, and fire extinguisher are in good reair. LPA Martinez reviewed one resident file and one employee file. One resident file was complete. Staff 1's (S1) file did not have first aid/CPR training certificate.

The exterior of the facility was clean and clear of debris. The emergency exterior gate is in good repair. The facility had required postings throughout the facility. The facility has a 30 day supply of PPE. The facility has one main screening entry point. The facility has covid-19 postings throughout the facility.

Based on this annual visit, there was one deficiency. The deficiency can be found on the 809-D page. An exit interview was conducted, and a copy of this 809 report, 809-d page, appeals rights were given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/04/2022 09:58 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: CALI CARE RETIREMENT HOME
FACILITY NUMBER: 342700029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2022
Section Cited

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87411Personnel Requirements - generally RCFE (c)(1) staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.
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Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. this requirement was not met as evidence by Staff 1 did not complete First Aid training. This posed a potential health and safety 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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2