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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700606
Report Date: 08/27/2026
Date Signed: 09/17/2026 08:42:14 AM

Document Has Been Signed on 09/17/2026 08:42 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:LAND PARK PLACEFACILITY NUMBER:
342700606
ADMINISTRATOR/
DIRECTOR:		LUCAS, YACUBFACILITY TYPE:
740
ADDRESS:6140 S LAND PARK DRIVETELEPHONE:
(916) 395-7773
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 6DATE:
08/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Jacub Lucas TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On August 27, 2026, at 2:05 PM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Jacub Lucas and explained the purpose of today's visit.

LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for six non-ambulatory residents. There are currently six residents who reside at this facility. The facility has an approved hospice waiver for six.

The LPA Martinez toured the facility with Jacub Lucas on August 27, 2026, at 4:00 PM.

LPA Martinez reviewed three out of three staff files, which were kept current. LPA Martinez reviewed three out of three resident files. Two out of three resident files did not have a current needs and service plan. LPA Martinez reviewed two out two medication administration records (MAR). Resident 1's (R1) MAR was not maintained, the last recorded administration sign off's for 13 medications were between August 19, 2026, and August 20, 2026. It is unknown if the medications were administered because the bubble packs did not have a start day. It was also observed that medication is not being popped out of the bubble pack in sequence, or following numerical calendar dates, therefore, LPA Martinez was unable track pill count. Additionally, R1's MAR indicates Donepezil 10 MG has been discontinued, however, the bubble pack was combined and stored with the current routine medication. The Donezpezil 10 MG bubble pack did not indicate that medication was discontinued. Continued....

Arielle Pascua
Avelina Martinez
DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2026
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
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: LAND PARK PLACE
FACILITY NUMBER: 342700606
VISIT DATE: 08/27/2026
NARRATIVE
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Resident 2's (R2) MAR was not maintained, and the last recorded administration sign offs for 20 medications were between August 19 2026, and August 20, 2026. It was also observed that medication is not being popped out of the bubble pack in sequence, or following numerical calendar dates, therefore, LPA Martinez was unable track pill count. It is unknown if medication has been administered.

The facility has a natural disaster plan. The last recorded emergency drill was on April 06, 2026, and was conducted from 10:00 AM to 10:30 AM. There was no other documentation indicating that emergency drills were conducted during other shifts. The facility has an infection control plan.

Facility was kept sanitary and furnished. The facility had an adequate food supply. The common areas and bedrooms were furnished and kept sanitary. The facility temperature measured at 78 degrees, and the water temperature measured at 105 degrees. The facility had an adequate food supply. The facility fire extinguisher was in good repair. The smoke detectors and carbon detectors were in good repair. The exterior of the home was clear of debris, and the emergency exit gate was in good repair.

Based on this annual inspection, the facility was not in compliance with Title 22 regulations. Deficiencies can be found on 809D-Page. An exit interview was conducted, and a copy of this 809 report, 809D Page, and appeals rights were provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/17/2026 08:42 AM - It Cannot Be Edited


Created By: Avelina Martinez On 08/27/2026 at 03:41 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: LAND PARK PLACE
FACILITY NUMBER: 342700606

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) 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 cited above in [2] out of [2t] [Medication Administration Records were not maintained and it is unknown if medications were administer due to there is no written documentation to prove medications were administer] which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2026
Plan of Correction
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Facility staff agrees to conduct an In-service regarding maintaining medication records and administering medication by a medical professional or by an approved CDSS approved continuing education vendor by POC date September 10, 2026. In-service training documents shall be emailed to LPA Martinez by POC date September 15, 2026, by 5:00 PM.
Type B
Section Cited
CCR
87463(i)
Reappraisals
(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making.

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] [resident files] did not have a current Needs and Service Plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2026
Plan of Correction
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Facility staff agrees to conduct a resident file audit, and update all outdated needs and services plan by POC date September 15, 2026. Facility staff shall email LPA Martinez updated needs and service plans by September 10, 2026, by 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.
Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/17/2026 08:42 AM - It Cannot Be Edited


Created By: Avelina Martinez On 08/27/2026 at 03:41 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: LAND PARK PLACE
FACILITY NUMBER: 342700606

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. The last emergency drill was conducted on April 06, 2026 PM, and it was only conducted at one shift from 10:00 AM to 10:30 AM which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2026
Plan of Correction
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Facility staff agrees to conduct an emergency drill by September 03, 2026. Facility staff shall email LPA Martinez emergency drill documentation by September 15, 2026, by 5:00 PM.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2026


LIC809 (FAS) - (06/04)
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