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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700643
Report Date: 03/25/2022
Date Signed: 03/25/2022 04:54:39 PM

Document Has Been Signed on 03/25/2022 04:54 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SOLSIE 2 CAREHOMEFACILITY NUMBER:
342700643
ADMINISTRATOR:FRICIA SOL-SIERRAS,CAMINAFACILITY TYPE:
735
ADDRESS:5319 APPLEHURST WAYTELEPHONE:
(209) 986-1914
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 3DATE:
03/25/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:staff Reynaldo SerillaTIME COMPLETED:
04:55 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) Anthony Tuck arrived at the facility on 03/25/2022 unannounced. LPA was met by Administrator (Admin) Camina Sol-Sierras and explained the reason for the visit to conduct a case management visit regarding a past SIR received back on 11/01/2021.

LPA reviewed the SIR regarding a resident (R1) complaining of pain on her chest. LPA learned that the R1 received the burns from her boyfriend’s friend when she was visiting her boyfriend and participating in smoking recreational marijuana. LPA learned from a conversation conducted with the Admin that the R1 goes out to visit her boyfriend at an undisclosed location. LPA learned from the Admin that the R1 has refused to give the location of where her boyfriend lives and refuses to provide the phone number to contact her boyfriend. LPA learned that the R1 is provided transportation to the light rail station by the Admin and or staff where R1 then purchases a ticket to ride the light rail train to an unknown destination to meet with her boyfriend. LPA requested and reviewed a copy of the LIC 602 and IPP report for R1. LPA learned that R1 is not allowed to leave the facility unassisted. LPA learned from the Admin, that R1 is picked up from the light rail station by the Admin and or staff when R1 calls the facility to let them know she is on her way home. Upon review of the IPP for R1, LPA learned that R1 goes to visit her boyfriend frequently during the week and R1 is not conserved, and it’s noted that R1 is independent. It was also noted in the IPP report that R1 smokes cigarettes and marijuana. Admin stated that she will schedule an appointment with physician for R1 to have R1 re-assessed to see if the LIC 602 can be updated due to conflicting information on the IPP.

Based upon review of information obtained, the following Title 22 regulation violation is being cited on the LIC 809D. Failure to correct the deficiency may result in civil penalties. Exit interview conducted with Camina Sol-Sierras a copy of the report and appeal rights were provided upon exit.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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 03/25/2022 04:54 PM - It Cannot Be Edited


Created By: Anthony Tuck On 03/25/2022 at 04:25 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SOLSIE 2 CAREHOME
FACILITY NUMBER: 342700643

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2022
Section Cited
CCR
80078(a)

1
2
3
4
5
6
7
80078(a) Responsibility for Providing Care and Supervision
The licensee shall provide care and supervision as necessary to meet the client's needs.This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee is to submit a plan for supervised visits for resident when personal friends come to visit at the facility. Licensee shall submit POC to CCLD by POC due date.
8
9
10
11
12
13
14
Based on documentation received, interviews conducted, Licensee did not ensure that care and supervision of a resident was being met during the transportation to an offsite location. This poses a potential threat to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Anthony Tuck
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2