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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700643
Report Date: 07/20/2022
Date Signed: 07/20/2022 03:30:28 PM

Document Has Been Signed on 07/20/2022 03:30 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: 4DATE:
07/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Camina SierrasTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conduct a case management visit. LPA Truong met with Administrator Camina Sierras and stated the purpose of the visit.

The purpose of the case management visit was to follow up on concerns found during a separate complaint investigation. It was learned through interviews and records review that there were no awake staff at night as indicated on the facility's Program Design. Staff (S2) stated that staff sleep when residents are asleep. Staff (S1) stated that he has fallen asleep on 2/19/22, the date of the incident. The facility program design indicated that night shift staff are always expected to be awake.

During today's visit, administrator Camina Sierras advised that her administrator certificate expired 2/6/22 and the renewal application was submitted to Certification Unit in December. Camina advised that she is the current Administrator. Her administrator certificated has been renewed. Expi

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited during this visit. See LIC 809-D. An exit interview was held and a copy of this report and appeal rights was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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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Document Has Been Signed on 07/20/2022 03:30 PM - It Cannot Be Edited


Created By: Tung Truong On 07/19/2022 at 11:45 AM
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: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2022
Section Cited
CCR
80022(k)

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80022(k) Plan of Operation. The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so.
This requirement is not met as evidenced by:
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Licensee/Administrator shall provide to CCL an addendum to the facility plan of operation to have a plan in place to ensure that there is a night staff awake to provide care and supervision. Proof of correction is due to CCL by 7/27/22.
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Based on interviews and records review, the licensee did not operate in accordance with the terms specified in the Program Design. The facility does not have night staff awake as specified in the program design. This poses a potential, Health, Safety or Personal Rights risk to clients in care.
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The facility will submit a new staffing schedule (LIC 500) by the POC due date that demonstrates the staffing requirements stated in the plan of operation are met. Proof of correction is due to CCL by 7/27/22.

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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Tung Truong
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022


LIC809 (FAS) - (06/04)
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