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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700716
Report Date: 03/24/2025
Date Signed: 03/24/2025 11:58:04 AM

Document Has Been Signed on 03/24/2025 11:58 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:MIRANDA GARDENSFACILITY NUMBER:
342700716
ADMINISTRATOR/
DIRECTOR:		MIRANDA, IANFACILITY TYPE:
735
ADDRESS:2405 RENWICK AVETELEPHONE:
(916) 896-1919
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
03/24/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Pamela MirandaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Vincent Moleski and Sommer Hayes arrived unannounced to conduct a case management visit. LPAs Moleski and Hayes met with administrator Pamela Miranda and explained the purpose of the visit.

LPA Moleski received a Facility Action Report (FAR) from Alta California Regional Center (ACRC) dated 3/17/25. The FAR identified several substantial inadequacies stemming from a visit made by ACRC representatives on that date. According to the FAR, two medications stored for a resident (R1) were not logged in the facility's centrally stored medication records. In an interview, Miranda said that she had marked the start dates for the medications on their packaging, but forgot to enter them into the centrally stored medication records. LPA Moleski observed that the medications had since been logged into the centrally stored medication records.

The FAR also noted that one of these medications did not have a PRN letter on file, identifying R1's ability to determine their needs for medication and communicate their symptoms. Miranda said that she acquired a new PRN authorization letter for this medication. LPA Moleski reviewed a PRN letter dated 3/18/25.

This facility is hereby cited per 22 CCR Sections 80075(k)(7) and 80075(b)(5). An exit interview was held with Miranda. Appeal rights and a copy of this report were left with Miranda.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2025
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 03/24/2025 11:58 AM - It Cannot Be Edited


Created By: Vincent Moleski On 03/24/2025 at 11:10 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MIRANDA GARDENS
FACILITY NUMBER: 342700716

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2025
Section Cited
CCR
80075(k)(7)

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"(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following..." This requirement was not met as evidenced by:
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Licensee has already updated the client's centrally stored medication record appropriately. This POC will be cleared.
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Based on record review and interview, a client's medications were not logged in the centrally stored medication records, which poses a potential health, safety, and/or personal rights risk.
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Type B
03/31/2025
Section Cited
CCR80075(b)(5)

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"(5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration..." This requirement was not met as evidenced by:
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Licensee acquired a PRN authorization form for this medication as of 3/18/25. This POC will be cleared.
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Based on record review and interview, a client did not have a PRN authorization letter on file for a medication, which poses a potential health, safety, and/or personal rights risk.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2025


LIC809 (FAS) - (06/04)
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