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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700087
Report Date: 06/11/2026
Date Signed: 06/11/2026 04:20:32 PM

Document Has Been Signed on 06/11/2026 04:20 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:SOUTH LAND PARK HILLS RCFEFACILITY NUMBER:
342700087
ADMINISTRATOR/
DIRECTOR:		ESTIFANIE A. TUALAFACILITY TYPE:
740
ADDRESS:7340 BARR WAYTELEPHONE:
(916) 266-3030
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 6DATE:
06/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Mary Frances OretaTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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 On June 11, 2026, at 9:30 AM, Licensing Program Analyst (LPA) Avelina Martinez and Analyst Henry Galan made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez and Analyst Henry Galan met with Angeline Kang and Mary Frances Oreta and explained the purpose of today's visit.

Administrator holds current certificate. The facility is licensed for six non-ambulatory clients, which one can be bedridden. There are currently six residents whom reside at this facility. The facility has an approved hospice waiver for six.

During today's annual inspection, LPA Martinez and Analyst Henry Galan reviewed six resident file, six staff files, and three medication administration records (MAR). The staff and resident files were maintained. The facility has an infection control plan. The facility does not have a LIC 610e Emergency and Disaster Plan for Residential Care Facilities For the Elderly. Additionally, emergency drill have not been conducted quarterly.



LPA Martinez and Analyst Henry Galan reviewed three resident Medication Administration Record (MAR). Resident 1 (R1) MAR had discrepancies. Senna 8.6 MG take one tablet by mouth twice daily. At 11:00 AM, LPA Martinez observed that the June 11 2026, 5:00 PM MAR data entry for Senna 8.6 was signed off indicating the medication was administered before 5:00 PM. Resident 2 (R2) does not have medication order documentation. R2's MAR states the following: Omeprazole 20 MG: 1 capsule by mouth in the morning for GERD. The Omeprazole 40 MG medication bottle order label states take 1 capsule by mouth two times daily before meals. R2 is being administered Vitamin B Complex; however, the Vitamin B Complex bottle does not have order label. Continued...
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2026
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: SOUTH LAND PARK HILLS RCFE
FACILITY NUMBER: 342700087
VISIT DATE: 06/11/2026
NARRATIVE
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 In addition, the facility does not have a medication/doctor order for the Vitamin B complex medication. R2 is being administered 1500 MG Vitamin C Complex daily. The facility does not have a medication/doctor order for the 1500 MG Vitamin C Complex medication. Also, the 1500 MG Vitamin C Complex medication bottle does not have a label. Acetaminophen 500MG medication bottle did not have a label, and the facility does not have a medication/doctor order.

Annual inspection will require additional review, and LPA Martinez will return at a later date to conduct a continuation annual inspection.

Incidental and Medical and Dental Care Services and, Health and Safety Code citations can be found on 809 D-Page.

An exit interview was conducted, and a copy of this report was provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2026 04:20 PM - It Cannot Be Edited


Created By: Avelina Martinez On 06/11/2026 at 02:57 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: SOUTH LAND PARK HILLS RCFE
FACILITY NUMBER: 342700087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. The facility has not conducted quarterly emergency drills which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2026
Plan of Correction
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Facility staff agree to conduct emergency drills at every shift by POC date June 12, 2026. Facility staff agrees to email emergency drill documentation by June 12, 2026,PM.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2026 04:20 PM - It Cannot Be Edited


Created By: Avelina Martinez On 06/11/2026 at 02:58 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: SOUTH LAND PARK HILLS RCFE
FACILITY NUMBER: 342700087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [2] out of [2] medication bottles did not have labels, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2026
Plan of Correction
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Facility staff agrees to obtain medication orders from R2's primary care physicians, and update R2's MAR by POC date June 18, 2026. Facility staff agrees to email Medication order and MAR to LPA Martinez by June 18, 2026, by 5:00 PM
Section Cited
Deficient Practice Statement
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3
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2026 04:20 PM - It Cannot Be Edited


Created By: Avelina Martinez On 06/11/2026 at 02:59 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: SOUTH LAND PARK HILLS RCFE
FACILITY NUMBER: 342700087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above the facility does not have a natural disaster plan and does not have a completed LIC 610e which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2026
Plan of Correction
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Facility staff agrees to complete a LIC 610e by POC date July 02, 2026. Facility staff agrees to email LIC 610e by POC date July 02, 2026 by 5:00 PM.
Section Cited
Deficient Practice Statement
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3
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/11/2026 04:20 PM - It Cannot Be Edited


Created By: Avelina Martinez On 06/11/2026 at 03:06 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: SOUTH LAND PARK HILLS RCFE
FACILITY NUMBER: 342700087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
87465(h)(6) Incidental Medical and Dental Care: The following requirements shall apply to medications which are centrally stored: The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. R1 and R2's MARs were not maintained, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2026
Plan of Correction
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Facility staff agrees to conduct an Incidental and medical and medication administration in-service training for all staff by POC date 07/02/2026. the in-service training shall be conducted by a third party medical audit company.
Type B
Section Cited
CCR
87465(a)(4)
87465(a)(4) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section. Based on R1 and R2's MAR discrepancies it is unknown if medication is being administered as required which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2026
Plan of Correction
1
2
3
4
Facility staff agrees to conduct an Incidental and medical and medication administration in-service training for all staff by POC date 07/02/2026. the in-service training shall be conducted by a third party medical audit company.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2026


LIC809 (FAS) - (06/04)
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