342700772-5-18-2026-27-AS-AVIA-DU7RDC-20260518125542

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700772
Report Date: 05/18/2026
Date Signed: 05/18/2026 12:56:14 PM

Document Has Been Signed on 05/18/2026 12:56 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	CURLY ANNE'S RESIDENCE, INC		FACILITY NUMBER:	342700772
ADMINISTRATOR/ DIRECTOR:	DE LOS SANTOS, MARY ANNE		FACILITY TYPE:	740
ADDRESS:	10435 DANICHRIS WAY		TELEPHONE:	(916) 585-9577
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY: 6		CENSUS: 6	DATE:	05/18/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Mary Anne Delos Santos		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE

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On May 18, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct the annual inspection visit. LPA initially met with staff on duty, Maria Corazon Mayberry (S1) and explained the purpose of the visit. The licensee, Mary Anne De los Santos (AD) was notified and arrived shortly after. Present during this visit were 6 residents in care with 2 staff on duty (S1, S2)

Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 non-ambulatory elderly residents. Facility does not have clearance for bedridden, delayed egress, and/or locked interior/exterior. Facility does not manage resident cash resources. Facility has a hospice waiver for 3 residents.

Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas.

LPA inspected 5 resident bedrooms and 3 bathrooms. Each bedroom has its own exit to the outside. Bathrooms are equipped with non-skid flooring; faucet, toilet and shower are in working condition. Hot water temperature was 105 degrees Fahrenheit in one of the bathrooms. Room temperature was maintained at 72 degrees Fahrenheit throughout this visit. Advisory provided to obtain a commode for the bathroom labeled “staff” in placed of a grab bar.

Fire extinguisher was observed in the dining/living area and last serviced on 4/1/26. LPA observed adequate amount of linen and towels supplies.

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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

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: CURLY ANNE'S RESIDENCE, INC	FACILITY NUMBER: 342700772
	VISIT DATE: 05/18/2026

NARRATIVE

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In the kitchen, LPA observed at least 7-day nonperishable and 2-day perishable food items. LPA observed proper food storage as evidenced by food containers labeled with date. Knives and other sharps were locked in drawer. Refrigerator and freezer were maintained at regulatory temperatures. In the refrigerator door (left side), LPA found a liquid medication labeled Nyguil that belonged to staff. This was observed to be accessible to residents in care. The small refrigerator located on the kitchen counter where they keep insulin did not have a lock. During this visit, AD obtained a locked box for these medication and placed it in the refrigerator.

The exit at the kitchen area going to the backyard did not have a ramp. Advisory was provided to AD to obtain a ramp for this exit.

Outdoor area was inspected. Advisory was provided to trim the vegetation on both of the walkways to the exit gates. During this visit, staff were trimming the plants. Fence on the left side when facing the house, it was leaning. Advisory was provided to fix this side of the fence. No bodies of water were observed at this time. Advisory was provided to ensure there is a shaded area for outdoor activities. AD stated she will replace the cover of the patio shade.

Record Reviews: Review of 3 of 6 resident (R1, R2, & R3) files was conducted, including but not limited to, review of Admission Agreement, Physician Reports, Centrally Stored Medication Record and Ambulatory Status. Advisory was provided to AD to obtain PRN Authorization Letter, even for those residents that do not have PRN medications. Advisory was provided to ensure all residents have their care plan updated annually. Advisory was provided to update restricted health care plan for those residents with restricted health care condition.

Medication reviews were conducted for 3 residents. No issues at this time.

Review of 4 staff files included but not limited to background clearance, first aid/CPR certification, and training.

Interviews: conducted with 1 resident and 1 staff on duty.

Documents Requested: LPA requested a copy of updated Liability Insurance Certificate, LIC500, and LIC308.

Per the California Code of Regulations, Title 22, Division 6, deficiencies were cited and advisories were provided.

Exit interview was conducted with AD. A copy of the report was provided upon exit.

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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/18/2026 12:56 PM - It Cannot Be Edited

Created By: Arvin Villanueva On 05/18/2026 at 12:36 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CURLY ANNE'S RESIDENCE, INC	FACILITY NUMBER: 342700772
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. During kitchen observation, LPA observed medication inside the kitchen refrigerator. Additionally, LPA observed the small refrigerator for insulin did not have a lock. These pose an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/19/2026
	Plan of Correction
1 2 3 4	Corrected on site: Licensee obtained a locked box for the insilin and other medications requiring refrigeration and placed the box inside the kitchen refrigerator. Per licensee, she will train staff regarding the proper storage of medication. Licensee agreed to submit proof of training to the Department by 5/22/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:

	Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

LIC809 (FAS) - (06/04)

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