<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700194
Report Date: 11/06/2024
Date Signed: 11/06/2024 11:43:48 AM

Document Has Been Signed on 11/06/2024 11:43 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:NORRIS SENIOR HOMEFACILITY NUMBER:
342700194
ADMINISTRATOR/
DIRECTOR:		VERA, NAZARINA DEFACILITY TYPE:
740
ADDRESS:4184 ENGLE ROADTELEPHONE:
(916) 571-5650
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Von Vega and Nazerina VegaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Holly Williams and Licensing Program Manager Czarrina Camilon-Lee arrived unannounced to conduct an annual inspection. LPM Camilon-Lee and LPA Williams met with facility administrator Nazarina Vega explained the purpose of the visit.

LPM Camilon-Lee LPA Williams reviewed five resident files (R1-R5) and three staff files (S1, S2, S4).
LPM Camilon-Lee and Williams toured the facility with Caregiver Nolan Geronimo and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. Door to outside in the double client room when opened had a cable cord that was exposed and is a fall hazard. The facility temperature was 72 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 137 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPM Camilon-Lee and LPA Williams observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPM Camilon-Lee and LPA Williams observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPM Camilon-Lee and LPA Williams observed a locked cabinet for the storage of medication. LPA Williams observed a residents medication unlocked in the kitchen. LPAs Moleski and Williams observed locked cabinets for the storage of cleaning solutions and knives. LPA Williams when in the unlocked garage observed poisons and laundry detergents out for residents to access. LPA Williams observed in the backyard a shed that is not permitted, contained a bed, and staff is sleeping in the shed. LPA Williams

LPM Camilon-Lee and LPA Williams interviewed three residents.

This facility is being cited per 22 CCR Section 87303(e)(1), 87305(a), 87309(a)(1) . An exit interview was held with Nazerina Vega. Appeal rights and a copy of this report were handed to Nazerina Vega.
Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
Holly WilliamsTELEPHONE: 916-798-3161
DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/06/2024 11:43 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: NORRIS SENIOR HOME
FACILITY NUMBER: 342700194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not have a water temperature in the required range. The water temperature was 137 degrees farenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
1
2
3
4
Licensee send a statement stating that the licensee will monitor water on a regular basis. Licensee to submit a picture of readings of the water temperature for the next three days..
Section Cited
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not lock up poisons and laundry detergent in the garage and the backyard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
1
2
3
4
Licensee agrees to put a lock on the garage door by 11/13/24. Licensee agrees to send a statement stating that they will lock up all medications and poisons 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.
Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
Holly WilliamsTELEPHONE: 916-798-3161

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024

LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 11/06/2024 11:43 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: NORRIS SENIOR HOME
FACILITY NUMBER: 342700194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not obtain a building permit and has staff living in shed in backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
1
2
3
4
Licensee agrees to get the shed permitted by 1/3/24 . Licensee agrees to send a statement by POC due date that no one will live in the shed until permitted by POC due date. Holly.williams@dss.ca.gov
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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-LeeTELEPHONE: (916) 263-4700
Holly WilliamsTELEPHONE: 916-798-3161

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024

LIC809 (FAS) - (06/04)
Page: 7 of 7