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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700805
Report Date: 01/22/2026
Date Signed: 01/22/2026 04:58:02 PM

Document Has Been Signed on 01/22/2026 04:58 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:NORTHERNCARE FACILITYFACILITY NUMBER:
342700805
ADMINISTRATOR/
DIRECTOR:		WOODWARD, ROSE BALUROFACILITY TYPE:
740
ADDRESS:5016 WATERBURY WAYTELEPHONE:
(530) 762-8199
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: DATE:
01/22/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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On 1/22/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Admin

During complaint investigations for complaints 59-AS-20251119202205 and 59-AS-20251208154031 LPA Mknelly obtained evidence for the following additional violations:
87465 Incidental Medical and Dental Care (h)(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. There was not a recording of R1 skin treatment in the centrally stored medication record.
87355 Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility. This requirement was not met based on records review and interview that found S1 and S2 did not have verified clearance prior to living and working at the home 5/27/25- 5/28-25.
87405 Administrator - Qualifications and Duties (d) (2) Knowledge of and ability to
conform to the applicable laws, rules and regulations. Administrator failed to hiring, train, seek criminal record clearance of S1 and S2, meet reporting requirements, ensure fire safety, create initiate resident behavior plans, ensure infection control and to have been arguing with family in the presence of residents.
Report continued...
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Kevin Mknelly
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2026
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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: NORTHERNCARE FACILITY
FACILITY NUMBER: 342700805
VISIT DATE: 01/22/2026
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require. This requirement was not met based on interviews that Administrator failed to report R1 fall, R1 pressure injuries, R1 Hospice, R1 death, scabies, pest infestation and a broken dryer.
87555 General Food Service Requirements (b)(8) All food shall be of good quality… Food in damaged containers shall not be accepted, used or retained. This requirement was not met based on observation that on 12/11/25, canned goods past use by dates and some with damaged labeling were present in the kitchen. This posed a potential risk to residents.

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed. Copy of report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Kevin Mknelly
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/22/2026 04:58 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 01/22/2026 at 12:13 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: NORTHERNCARE FACILITY
FACILITY NUMBER: 342700805

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2026
Section Cited
CCR
87355(c)

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Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility… This requirement was not met based on records review and
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Licensee will submit a statement of understanding and intent to comply with this requirement by the POC date of 1/23/26.
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interview that found S1 and S2 did not have verified clearance prior to living and working at the home 5/27/25- 5/28-25.
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Type B
01/30/2026
Section Cited
CCR87405(d)(2)

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Administrator - Qualifications and Duties (d) (2) Knowledge of and ability to
conform to the applicable laws, rules and regulations. Administrator failed to hiring, train, seek criminal record clearance of S1 and S2, meet reporting requirements, ensure fire safety, create initiate resident
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Licensee will submit proof of registration for CEUs to cover training for the deficiencies sited by the POC date of 1/30/26.
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 behavior plans, ensure infection control and to have been arguing with family in the presence of residents. This posed a potential risk to residents.
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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.
Maribeth Senty
NAME OF LICENSING PROGRAM MANAGER:
Kevin Mknelly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/22/2026 04:58 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 01/22/2026 at 12:21 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: NORTHERNCARE FACILITY
FACILITY NUMBER: 342700805

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2026
Section Cited
CCR
87465(h)(6)

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Incidental Medical and Dental Care (h)(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. There was not a recording of R1 skin treatment in the centrally stored medication record.
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Licensee will audit and update all resident storage records and demonstrate records are complete and accurate by the POC date of 2/6/26.

This POC to be cleared by visit.
Type B
02/06/2026
Section Cited
CCR
87211(a)

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Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require. This requirement was not met based on interviews that Administrator failed to report incidents identified. This posed a potential risk to residents.
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Licensee will submit a statement of understanding of this requirement as well as a policy of the process from an incident, notifications and submitting written reports by the POC date of 2/6/26.
Type B
02/06/2026
Section Cited
CCR87555(b)(8)

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General Food Service Requirements (b)(8) All food shall be of good quality… Food in damaged containers shall not be accepted, used or retained. This requirement was not met based on observation. This posed a potential risk to residents.
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Licensee will conduct an audit of all food supplies and ensure all food is safely stored and organized in a way that allows for easy identification of "first in/ first out" procedures
by the POC date of 2/6/26.
POC to be cleared by visit.

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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.
Maribeth Senty
NAME OF LICENSING PROGRAM MANAGER:
Kevin Mknelly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2026


LIC809 (FAS) - (06/04)
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