342700759-5-20-2025-27-AS-CTAO-DGUPGS-20250520111848

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700759
Report Date: 05/20/2025
Date Signed: 05/20/2025 11:19:14 AM

Document Has Been Signed on 05/20/2025 11:19 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:	ROSEMARY'S WILLOW GROVE HOME		FACILITY NUMBER:	342700759
ADMINISTRATOR/ DIRECTOR:	BITANCOR, ROSEMARY		FACILITY TYPE:	740
ADDRESS:	8559 WILLOW GROVE WAY		TELEPHONE:	(916) 688-7576
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY: 4	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	05/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:02 AM
MET WITH:	Rosemary Bitancor		TIME VISIT/ INSPECTION COMPLETED:	11:47 AM

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	On 5/20/25 at 9:00 AM, Licensing Program Analyst (LPA) Cynthia Tamayo arrived at the facility to conduct an unannounced annual inspection. LPA Tamayo met with Licensee, Rosemary Bitancor and explained the purpose of the visit. Licensee assisted with today’s visit. Administrator certificate # is 6017166740and will expire on 7/7/2025. The current census is 3 with 2 facility staff. This facility is a single story building licensed to serve six (4) non-ambulatory residents. LPA Tamayo inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Tamayo observed the facility to be free of odor, clean and in good repair. There are no bodies of water present. LPA observed the following: KITCHEN: Appliances and fixtures were clean and functional. LPA observed seven-day non-perishable and two-day perishable food supplies. Meals are prepared by the Staff. Fridge temperature was at 45 degrees F and freezer temperature was at 0 degrees F. Knives and other sharps are locked inaccessible in a drawer. Kitchen and house cleaning supplies are stored in a locked cabinet located under the sink. COMMON AREAS: Common areas include the Living Room and Dining Room. All furniture was observed to be clean and in good condition, with ample seating. There was space to accommodate both indoor and outdoor activities. LPA noted an Activity Calendar in the hallway and activity storage in the living room area. Continued on 809-C

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Cynthia Tamayo	TELEPHONE: (916) 225-3582
	DATE: 05/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

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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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: ROSEMARY'S WILLOW GROVE HOME	FACILITY NUMBER: 342700759
	VISIT DATE: 05/20/2025

NARRATIVE

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One (1) fire extinguisher was observed throughout the common areas and was last serviced on 01/2025, and checked monthly. Smoke and carbon monoxide detectors are in compliance with fire safety. LPA observed the facility has a has a public telephone in the kitchen area and the facility has the required posters posted. Facility thermostat was observed at 74 degrees Fahrenheit. The first aid kit was checked and contained the required components.

GARAGE: LPA observed toxins located in the garage kept locked and inaccessible to residents and general extra stored items including but not limited to paper goods, washer machine and dryer.
EXTERIOR: Exterior passageways were clean and clear of any obstructions. There is a covered patio area for client and visitor use with furniture observed to be in good condition. Clients are supervised at all times when they are outside. There are two (2) gates with a self-latching mechanism for persons to exit the backyard in emergencies. LPA observed a locked shed which contains general supplies.

BEDROOMS: LPA inspected facility bedrooms. The facility has five (4) total private bedrooms. All bedrooms were observed to contain furniture, bedding and linens within regulation. Extra linens are stored in the hallway cabinet. Client bedrooms had no visible hazards or inconsistencies observed.
BATHROOMS: There are two (2) bathrooms: one (1) is a private bathroom attached to a resident bedroom and one (1) is a shared bathroom located in the hallway. All bathrooms were observed to be clean and sanitary, and supplied with paper and hygiene products. Water temperature was tested and measured at 114.2 degrees F in the kitchen and 105 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time.

MEDICATION REVIEW: LPA reviewed medications which are centrally stored in a locked cabinet in the hallway. All medications were stored and administered in compliance with regulation.

RECORD REVIEW: LPA reviewed four (4) resident file records at 10:30PM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. Resident files reviewed contained all required documents. LPA reviewed four (2) staff records during today's visit.
Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Cynthia Tamayo	TELEPHONE: (916) 225-3582
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

LIC809 (FAS) - (06/04)

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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: ROSEMARY'S WILLOW GROVE HOME	FACILITY NUMBER: 342700759
	VISIT DATE: 05/20/2025

NARRATIVE

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Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All staff records reviewed were in compliance at the time of the visit.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility's infection control plan as well as the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are within regulation. Both documents were observed to be complete and recently updated. Emergency disaster drill is conducted quarterly per regulation with the last drill documented on 05/04/2025. Personal Protection Equipment (PPE) and extra emergency supplies, including emergency food and water, are stored in the garage.

LPA Tamayo requested resident and staff files for review. LPA reviewed 4 resident files and they were complete. LPA reviewed 2 staff files and it was complete. LPA reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents were collected and will be added to the facility file:
(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate
(4) LIC 610 Current Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) LIC 500 Current Personnel Report
(7) LIC 309 Administrator Organization

As a result of this annual visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted with the Licensee, and a copy of these LIC 809 reports were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Cynthia Tamayo	TELEPHONE: (916) 225-3582
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

LIC809 (FAS) - (06/04)

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