342700831-9-24-2026-27-AS-SLOZ-DY8PJ4-20260924112055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700831
Report Date: 09/24/2026
Date Signed: 09/24/2026 11:21:18 AM

Document Has Been Signed on 09/24/2026 11:21 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:	HONEST LIVING		FACILITY NUMBER:	342700831
ADMINISTRATOR/ DIRECTOR:	TRAN, VINH		FACILITY TYPE:	740
ADDRESS:	9449 CHEVERNY WAY		TELEPHONE:	(916) 425-8161
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95829
CAPACITY: 6		CENSUS: 6	DATE:	09/24/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Staff Krist Tran		TIME VISIT/ INSPECTION COMPLETED:	11:30 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 September 24, 2026, at 9:00 AM, Licensing Program Analyst (LPA) Sulma Lopez arrived unannounced at the facility to conduct an annual required inspection. LPA Lopez met with Administrator 1 (A1) Lisa Saephan Tran and explained the purpose of today's visit. A1 had to leave the facility shortly after but LPA worked with Staff 1 (S1) Krist Tran for the rest of the visit. The Administrator holds current certificate #7019209740 and expires on June 19, 2027. The facility is licensed for 6 non-ambulatory residents. There are currently 6 residents who reside at this facility. The facility has an approved hospice waiver for 3. At 9:20 AM, LPA conducted record reviews of 6 staff and 6 resident files. Resident files were observed to contain Admission Agreements, LIC 602 Physician Reports, and TB Test Records. Three (3) out of six (6) resident files were missing Reappraisals. Staff files were observed to contain Health Screening, Background Clearance, and updated training records. At 10:15 AM, LPA conducted a medication review. Medications were stored in a locked cabinet. The facility uses an electronic MAR sheet to record all dispensed medication to residents. At 10:20AM, the LPA toured the facility with Staff 1 (S1). The facility was clean, safe, and in good repair. The kitchen was observed to be clean and contained cooking appliances that were operable. The facility had a menu posted on the refrigerator. The facility contained at least 2 days worth of perishable food items and at least 7 days of non-perishables. Fresh fruit was observed on the kitchen counter. Sharps and toxins were stored in a locked cabinet and kitchen drawer. Continued on LIC 809-C.

Arielle Pascua
Sulma Lopez
	DATE: 09/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

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: HONEST LIVING	FACILITY NUMBER: 342700831
	VISIT DATE: 09/24/2026

NARRATIVE

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LPA toured the resident bedrooms which were observed to be furnished with furniture that was in good repair. Each room contained a smoke detector on the ceiling. The resident beds contained clean bedding. The facility restrooms were clean and free of odors. Facility showers contained non-slip mats and grab bars for resident safety. A bottle of bleach toilet cleaner was observed to be stored under the unlocked restroom cabinet.

LPA visually inspected the staff room from the room entrance. The facility contained a workspace office for staff which contained a computer and facility files. The facility has equipment for laundry services. Detergent and bleach were stored above the laundry area cabinets. The cabinet contained a lock but it was not actually secured. LPA observed S1 engage the lock and secure the cabinet during the tour. The facility garage was locked and inaccessible to residents. The garage contained miscellaneous storage items.

The LPA observed a resident enjoying coffee at the dinner table and a second resident watching television in the living room. The dining room was clean and contained enough seating to accommodate the current census. The living room area was clean and free of odors. The LPA observed recliners available for each resident. The LPA observed a bottle of acetone stored in an unlocked cabinet in the hallway.

The facility temperature was 73 degrees. The hot water temperature was 116 degrees. Fire extinguishers were serviced annually on April 27, 2026.

The exterior of the facility was observed to contain a shaded patio area with outdoor furniture. A resident was observed in the outdoor seating area. The facility's side exit and perimeter fence were in good repair.

The Licensee requested the following documents to be emailed/ faxed to the Regional Office within 15 days:
- LIC 500 Personnel Report, LIC 308 Designation of Facility Representative, LIC 610E Emergency and Disaster Plan, and copy of Liability Insurance Certificate.

As a result of this annual inspection, deficiencies were cited on the LIC 809-D. An exit interview was conducted and a copy of this report, the LIC 809-D, and Appeal Rights were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Sulma Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/24/2026 11:21 AM - It Cannot Be Edited

Created By: Sulma Lopez On 09/24/2026 at 11:00 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: HONEST LIVING	FACILITY NUMBER: 342700831
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not ensure that bleach, acetone, and detergent were stored in locked storage areas which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/23/2026
	Plan of Correction
1 2 3 4	The Facility agrees to conduct an in-service training with staff to train on safe storage practices for toxins and submit a copy of the training roster to the LPA by October 23, 2026 by 5:00PM.

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not ensure that 3 out of 6 resident reappraisals were completed at least every 12 months poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/23/2026
	Plan of Correction
1 2 3 4	The facility agrees to complete resident reappraisals for 3 out of 6 residents whose reappraisals were expired and email copies to the LPA by October 23, 2026 by 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.

	Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:

	Sulma Lopez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

LIC809 (FAS) - (06/04)

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