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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700060
Report Date: 08/14/2024
Date Signed: 08/14/2024 01:46:09 PM


Document Has Been Signed on 08/14/2024 01:46 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:LEVENDI ESTATE, THEFACILITY NUMBER:
342700060
ADMINISTRATOR:BERCI, ADRIANFACILITY TYPE:
740
ADDRESS:4107 LEVENDI LNTELEPHONE:
(916) 333-4641
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 5DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ramona Del RoyTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Holly Williams and Vincent Moleski arrived unannounced to conduct an annual inspection. LPAs Williams and Moleski met with facility administrator Ramona Del Roy and explained the purpose of the visit.

LPA Williams and Moleski reviewed 5 resident files (R1-R5) and 2 staff files (S1-S2). Upon arrival, LPAs Williams and Moleski observed a caregiver in the facility (S3). LPAs Moleski and Williams reviewed Guardian records and observed that S3 was not fingerprinted and had no criminal record clearance. Del Roy confirmed that S3 had yet to be fingerprinted. LPAs Moleski and Williams observed that S2 had no tuberculosis test taken during their health screening. S2 confirmed that they had not received a TB test prior to starting work.

LPAs Williams and Moleski toured the facility with Del Roy and inspected common areas, the kitchen, bedrooms, bathrooms, garage, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 106 degrees Fahrenheit, which is below the required range of 105 and 120 degrees.

LPAs Williams and Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPAs Williams and Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPAs Williams and Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Williams and Moleski interviewed 1 staff member (S1) and 2 residents (R1-R2).

This facility is being cited per HSC Section 1569.17(c)(1)(A) and 22 CCR Section 87411(f). A civil penalty in the amount of $100 per day for a total of two days worked by S3 is hereby assessed. An exit interview was held with Del Roy. Appeal rights and a copy of this report were emailed to Ramona Del Roy.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
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 3


Document Has Been Signed on 08/14/2024 01:46 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: LEVENDI ESTATE, THE
FACILITY NUMBER: 342700060

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.17(c)(1)(A)
Licensing
(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, S3 worked for two days in this facility as a caregiver without a fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
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Licensee agrees to have S3 fingerprinted by POC due date.
holly.williams@dss.ca.gov
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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/14/2024 01:46 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: LEVENDI ESTATE, THE
FACILITY NUMBER: 342700060

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, S2 did not receive a TB test prior to starting work, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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Licensee agrees to acquire a TB test for S2 by POC due date.
holly.williams@dss.ca.gov

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: Holly WilliamsTELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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