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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700397
Report Date: 01/07/2025
Date Signed: 01/07/2025 03:03:04 PM

Document Has Been Signed on 01/07/2025 03:03 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:GUEVARRA RESIDENTIALFACILITY NUMBER:
342700397
ADMINISTRATOR/
DIRECTOR:		GUEVARRA, NAOMIFACILITY TYPE:
735
ADDRESS:5150 EULER WAYTELEPHONE:
(650) 580-8857
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 4CENSUS: DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:53 AM
MET WITH:Naomi Guevarra TIME VISIT/
INSPECTION COMPLETED:
03:18 PM
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On 01/07/25 at 11:53 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care staff Noel Roy. Care staff called and informed administrator Naomi Guevarra that CCLD was present in the facility. Administrator Naomi arrived approximately 15 minutes later. LPA Lee explained the purpose of the visit. Administrator assisted with today’s visit. Administrator certificate # is 700972835 and will expire on 12/09/25. The current census is 4 with 1 facility staff.

This facility is a single story building licensed to serve three (3) ambulatory and one (1) non-ambulatory client. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be in good repair. LPA Lee observed the client's bathroom not free of odor and clean. LPA Lee observed the bathroom shower wall had multiple mold patches and on the shower floor. During the visit, care staff Noel apply bleach and scrubbed the mold off the shower wall and shower floor. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 122.4 degrees Fahrenheit in client bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is in the kitchen and was last serviced on 10/21/24. The last fire drill was conducted on 12/23/24. LPA Lee observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. Facility thermostat was observed at 65 degrees Fahrenheit which is not within the required regulation of 68 to 85 degrees Fahrenheit.

Continued LIC 809-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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 5
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: GUEVARRA RESIDENTIAL
FACILITY NUMBER: 342700397
VISIT DATE: 01/07/2025
NARRATIVE
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LPA Lee observed toxins located in laundry cabinet and kept locked and inaccessible to clients. LPA Lee observed sharp knives kept locked in the staff room cabinet and inaccessible to clients. LPA Lee checked medication storage and found medication to be locked away and inaccessible to clients. LPA Lee reviewed and compared 2 out of 4 medication administration record (MAR) and it was complete. The first aid kit was checked and contained all the required components. LPA Lee requested client and staff files for review. LPA Lee reviewed 4 out of 4 client files and they were complete; however, 3 out of 4 client files didn’t have current Individual Progress Plan (IPP for 2024 and only for 2023. Administrator stated that the clients IPP was completed for 2024 but will get copies from the client’s Service Coordinator. LPA Lee reviewed 2 staff files and they were complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents was provided to LPA during today’s visit:
(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate
(4) LIC 610 Current Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) LIC 500 Current Personnel Report

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, LIC 9102 and Appeals rights were provided to the facility. The administrator was informed that a failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/07/2025 03:03 PM - It Cannot Be Edited


Created By: Pang Lee On 01/07/2025 at 02:14 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: GUEVARRA RESIDENTIAL
FACILITY NUMBER: 342700397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA Lee observed the client's bathroom not free of odor and clean. LPA Lee observed the bathroom shower wall had multiple mold patches and on the shower floor, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/14/2025
Plan of Correction
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During the visit, care staff Noel apply bleach and scrubbed the mold off the shower wall and shower floor. Administrator will review the regulaiton cited and email LPA Lee a statement of acknowlegement and understanding of the regulaiton cited. POC will be provided to LPA Lee by POC date 01/14/25 end of day 5:00 PM.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA Lee observed hot water temperature was measured at 122.4 degrees Fahrenheit in client bathroom sink, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/14/2025
Plan of Correction
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During the visit, administrator adjusted the hot water. Administrator will provied LPA Lee a water log temperature with pictues of the water temperature from 01/08/24 to 01/17/25 and email the log to LPA Lee. Administrator will review the regulaiton cited and email LPA Lee a statement of acknowlegement and understanding of the regulaiton cited. POC will be provided to LPA Lee by POC date 01/14/25 end of day 5:00 PM.
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-Lee
LICENSING EVALUATOR NAME:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
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