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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700961
Report Date: 12/20/2024
Date Signed: 12/20/2024 12:55:34 PM

Document Has Been Signed on 12/20/2024 12:55 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:COMFORTS OF HOME TREASUREFACILITY NUMBER:
342700961
ADMINISTRATOR/
DIRECTOR:		KANG, MARIAFACILITY TYPE:
740
ADDRESS:6997 TREASURE WAYTELEPHONE:
(916) 833-1493
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 5DATE:
12/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jackie ChanTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 12/20/24 at 9:00am. Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management deficiencies inspection to address deficiencies observed during a complaint investigation. LPA met with staff Jackie Chan and together discussed LPAs observations.

LPA did not receive and death report regarding the death of R1 (see confidential names list, LIC 811 dated 12/20/24). Staff member present had a copy of the incident report with other death reports from other facilities she is associated to and LPA did not observe an death report electronically filed for this facility and other facilities staff is associated with.

Upon a walk through of the facility, LPA observed two box cutters on a desk in the facility that were not stored inaccessible to residents in care and poses an immediate health and safety risk to residents in care. LPA also observed the facility did not have a two day perishable food supply and did not match the sample menu as the date was blank on the sample menu. LPA documented with photos.

LPA obtained statements from staff member that the administrator's last visit at the facility was over a month ago. Staff provided statements to LPA that administrator is being treated for an illness. LPA did not witness Administrator listed on any staff schedule for the prior two weeks.

Per California Code of Regulations, Title 22, the following deficiencies are cited during today's inspection.

Exit interview was conducted a copy of this report and appeal rights were provided to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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 12/20/2024 12:55 PM - It Cannot Be Edited


Created By: Kevin Gould On 12/20/2024 at 10:54 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: COMFORTS OF HOME TREASURE
FACILITY NUMBER: 342700961

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2024
Section Cited

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Storage Space: Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by, LPAs observations of two box cutters
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 on the desk next to the dining room area which poses an immediate health, safety or personal rights risk to residents in care.
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Type A
12/23/2024
Section Cited

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General Food Service Requirements: Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by LPA observations of inadequate two day
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 perishable as LPA only observed some eggs, bread, condiments and dessert and could not meet the items listed in the sample menu for the week of December 16th which poses an immediate health, safety and personal rights risk to residents in care.
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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:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/20/2024 12:55 PM - It Cannot Be Edited


Created By: Kevin Gould On 12/20/2024 at 11:07 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: COMFORTS OF HOME TREASURE
FACILITY NUMBER: 342700961

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2024
Section Cited

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Reporting Requirements: Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement was not met as evidenced by no
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notification was made to the department and no record of the report has been electronically filed by the department.
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Type B
01/10/2025
Section Cited

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Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
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This requirement is not met as evidenced by staff statements and LPA observations of facility files that the approved administrator is not present at the facility a sufficient number of hours to properly administer the facility and supervise the duties performed by staff which poses a potential health safety and personal rights risk to residents in care.
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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:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
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