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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700525
Report Date: 11/01/2023
Date Signed: 11/01/2023 11:43:41 AM


Document Has Been Signed on 11/01/2023 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ALMOND HEIGHTSFACILITY NUMBER:
342700525
ADMINISTRATOR:MACDONALD, STEPHENFACILITY TYPE:
740
ADDRESS:8685 GREENBACK LNTELEPHONE:
(916) 542-7988
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:145CENSUS: 111DATE:
11/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Stephen MacdonaldTIME COMPLETED:
11:45 AM
NARRATIVE
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On 11/01/23, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 10/12/23.LPA met with Executive Director (ED) , Stephen MacDonald and explained reason for visit.

On 10/20/23, the facility notified the Department via LIC624 (Incident Report) that R1 eloped from the facility on 10/12/23 and had returned after being located by law enforcement on 10/12/23. On 10/23/23, LPA Bains requested R1 facility records via email. On 10/25/23, LPA Bains followed up with the facility via email regarding the requested documents. On 10/25/23, Executive Director, Stephen MacDonald, advised the Department that records would be sent over by close of business. On 10/30/23, LPA Bains sent another follow up request for R1’s documents. As of this date, the Department has not received documents for R1 which were requested on 10/23/23, therefore citations are being issued pursuant to Title 22 and notated on the 809-D page attached herewith. Failure to submit Proof of Correction (POC) by Plan of Correction date may result in civil penalties.


Exit interview was conducted with ED and the report was reviewed.
Appeal rights and a copy of this report was left at the facility.






SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
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 2


Document Has Been Signed on 11/01/2023 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ALMOND HEIGHTS
FACILITY NUMBER: 342700525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2023
Section Cited
CCR
87506(d)

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87506-Resident Records- (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours…this requirement is not met as evidenced by;
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Facility shall provide all requested documents for resident, R1 to the department by POC date, 11/02/23 by 5pm via E-FAX/E-MAIL.
result in civil penalties.

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Facility did not provide requested documents to department related to resident, R1s elopement incident which were requested on 10/23/23,10/25/23 and 10/30/23 which poses a potential health and safety risks for residents in care.
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Failure to submit Proof of Correction (POC) by Plan of Correction date may result in civil penalties.


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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023
LIC809 (FAS) - (06/04)
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