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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700506
Report Date: 02/06/2024
Date Signed: 02/06/2024 04:46:39 PM


Document Has Been Signed on 02/06/2024 04:46 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:KENTFIELD ESTATES RANCH RCFEFACILITY NUMBER:
342700506
ADMINISTRATOR:SOUMAHORO, MARIAM GBATYFACILITY TYPE:
740
ADDRESS:3800 SILVER SPUR WAYTELEPHONE:
(916) 904-0027
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:6CENSUS: 5DATE:
02/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:CaregiverTIME COMPLETED:
04:55 PM
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On 2/6/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with caregiver. Administrator was notified and arrived to assist.

On 2/5/24, the department received a death report and phone contact from the administrator regarding the unexpected death of a resident. On 2/2/24 at approximately 6:30 AM, R1 had an unwitnessed fall from their wheelchair. Caregiver responded when they heard the fall. R1 was unresponsive. Caregiver initiated CPR and activated 9-1-1. R1 was unable to be revived.

Records review showed R1 to have extensive chronic health issues. R1 had limited verbal communication ability yet was constantly observed and no health concerns were apparent in the previous 24 hours. LPA observed the location of the fall outside the bathroom and found no hazards.

As a result of today’s inspection, no deficiencies were noted.
LPA did advise that the door lock be removed from the fire door to resident rooms. Licensee will consider installing a fire door release magnet system.

Report reviewed. Copy of report and appeal rights provided
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
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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