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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700029
Report Date: 03/14/2024
Date Signed: 03/14/2024 11:15:43 AM


Document Has Been Signed on 03/14/2024 11:15 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: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:
03/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Cynthia MojicaTIME COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski spoke with facility administrator Cynthia Mojica over the phone and explained the purpose of the visit. Mojica said staff member Reign Balilo could sign this report in her absence.

LPA Moleski reviewed an eviction notice sent by email to a resident's (R1's) responsible party. The notice, written by Mojica, was sent on February 20, 2024, and justified the eviction of R1 based on a "shortage of staff." The notice did not include a justification for eviction per 22 CCR Section 87224(a)(1-5), nor did it include specific facts to permit determination of the cause for eviction per 22 CCR Section 87224(d), nor did it include the components required per 22 CCR Section 87224(d)(1)(B-D).

This facility is being cited per 22 CCR Section 87224(a). An exit interview was held with Mojica. Appeal rights and a copy of this report were left with Balilo.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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 03/14/2024 11:15 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: CALI CARE RETIREMENT HOME
FACILITY NUMBER: 342700029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
87224(a)

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"The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)."

This requirement was not met as evidenced by:
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Licensee agrees to send a notice to R1's responsible party to rescind the eviction notice, and to copy LPA Moleski on the email.
vincent.moleski@dss.ca.gov
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Based on record review, the licensee issued an eviction notice which did not specify what needs previously not identified R1 had developed, if and/or when a reappraisal was conducted to determine if R1's level of care was insufficient, and furthermore did not identify any other legitimate cause for eviction, which poses a potential health, safety, and/or personal rights 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 RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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