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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700717
Report Date: 09/01/2023
Date Signed: 09/01/2023 10:29:33 AM

Document Has Been Signed on 09/01/2023 10:29 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:EVA LUIS RESIDENTIALFACILITY NUMBER:
342700717
ADMINISTRATOR:MANIQUIZ, LUISFACILITY TYPE:
735
ADDRESS:6845 CUNNINGHAM WAYTELEPHONE:
(916) 346-5602
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 4CENSUS: 3DATE:
09/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Luis ManiquizTIME COMPLETED:
10:40 AM
NARRATIVE
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09/01/2023 at 8:15 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to the facility to conduct a case management visit. LPA met with direct care giver, Virginia Chio who then called administrator, Luis Maniquiz. Administrator arrived approximately 10 minutes later. LPA Lee explained the purpose of the visit. The census is 3 with 2 facility staff. LPA Lee observed no client in the home. All clients were at day program.

LPA Lee received notification from Alta Regional that during a Title 17 monitoring review the facility has a shed in the courtyard that the facility is using the shed for staff when staff are not on schedule. At 8:30 AM LPA Lee and administrator Luis toured the shed in the courtyard. LPA Lee observed a twin bed with headboard, a clothes rack, a end table with night stand, a dresser, a table, a TV, a window with curtains, and an air conditioner . Based on interviews conducted with both administrator Luis and direct care staff Virginia Chio, it was learned that the facility started using the shed in the backyard as a staff live in on July 14, 2023 when staff 2 (S2) started working at the facility. According to the facility sketch floor plan the shed in the courtyard is used for storage. It was also learned that both staff (S1) and (S2) would sleep on the sofa in the common area when clients are sleeping at night. According to the facility plan of operation it states that "Staff member assigned during the night shift is expected to be awake."

As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. Failure to correct deficiencies may result in civil penalties. An exit interview was conducted with administrator Luis Maniquiz, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the administrator

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2023
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 09/01/2023 10:29 AM - It Cannot Be Edited


Created By: Pang Lee On 09/01/2023 at 09:42 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: EVA LUIS RESIDENTIAL
FACILITY NUMBER: 342700717

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
Section Cited
CCR
80086(a)

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80086(a) Alterations to Existing Building or New Facilities

(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This regulation was not met as evidence by:
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Licensee agrees to submit LIC 200, Application for a Community Care Facility and a new facility sketch floor plan of the interior and exterior of the facility to LPA Lee at pang.lee@dss.ca.gov by POC date 09/15/2023 by 5:00 PM end of day.
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Based on observations and interview, the licensee did not ensure to notify the department prior to alteration of the facility sketch floor plan. It was learned that the shed in the courtyard is now used for live in staff instead of a shed for storage, which poses/posed a potential health, safety or personal rights risk to persons in care.


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Licensee would also need to have the shed fire clearance cleared to have the shed used for live in staff.
Type B
09/15/2023
Section Cited
CCR80022(b)(5)

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80022(b)(5) Plan of Operation

(b) The plan and related materials shall contain the following:
(5) Staffing plan, qualifications, and duties, if applicable.

This regulation was not met as evidence by:

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Licensee agrees to review plan of operations and regulation cited. Licensee will submit a statement acknowledging that licensee have read and understood both plan of operations and regulation being cited.
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Based on observation and interviews, licensee did not comply to plan of operation. LIcensee did not ensure that there is staff member assigned during the night shift is awake, which poses/posed a potential health, safety or personal rights risk to persons in care.


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 Licensee will ensure that there is a staff AWAKE at all times during the client sleep hours. Licensee will email POC to LPA Lee at pang.lee@dss.ca.gov by 09/15/2023 by end of day 5:00PM.
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:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/01/2023 10:29 AM - It Cannot Be Edited


Created By: Pang Lee On 09/01/2023 at 10:00 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: EVA LUIS RESIDENTIAL
FACILITY NUMBER: 342700717

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
Section Cited
CCR
85087(a)(3)

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85087(a)(3) Buildings and Grounds

(a) In addition to Section 80087, bedrooms must meet, at a minimum, the following requirements:
(3) No room commonly used for other purposes shall be used as a bedroom for any person.

This regulation was not met as evidence by:

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Licensee agrees to review regulation cited and write a statement acknowledging that licensee have read and understood the regulation being cited. Licensee agrees to not have any facility staff sleep on the sofa in the common area at all times.
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Based on observation and interviews, licensee did not comply to building and grounds. Licensee is using the sofa in the common area for facility staff to sleep during client sleep hours,
which poses/posed a potential
health, safety or personal rights risk to persons in care.



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Licensee will email POC to LPA lee at pang.lee@dss.ca.gov by POC date 09/15/2023 by 5:00 PM by end of date.

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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:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023


LIC809 (FAS) - (06/04)
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