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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700984
Report Date: 06/20/2024
Date Signed: 06/21/2024 12:10:28 PM


Document Has Been Signed on 06/21/2024 12:10 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:SYCAMORE RESIDENTIAL CARE CENTER, B LLCFACILITY NUMBER:
342700984
ADMINISTRATOR:NASSAR, NADERFACILITY TYPE:
740
ADDRESS:4545 SYCAMORE AVENUE, UNIT BTELEPHONE:
(916) 595-9991
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:6CENSUS: 6DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:caregiverTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 6/20/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator was not available to assist. Inspection completed with staff assist

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, or personal rights violations were observed. The home is very clean and residents stated they are happy with care. LPA noted hot water temperature in the middle bathroom measured at 140 degrees. LPA advised residents be notified, a excessive hot water sign be posted while temperature is corrected. The other hot water control in the non-ambulatory end of the home is non-functional. Staff are using a door stop in the fire door. The practice is to be discontinued. An Ombudsman posted was not observed. Licensee to contact the Ombudsman's office.

LPA reviewed 6 resident files. 5 of 6 residents do not have updated needs and service plans on file within the past 12 months. R6 has a diagnosis of dementia and needs a updated physician's report.
LPA advised consistent use of a LIC 602a or the equivalent for senior medical assessments for all residents who are seniors.

LPA reviewed 2 staff files. Files are incomplete. S1 and S1 do not have health screens present on file. Training that is conducted on line was inaccessible. Licensee to send proof of training for S1 and S2

Deficiencies are being cited , on page LIC 809-D of this report, as a result of todays inspection.


Exit interview conducted with licensee and copy of report and appeal rights left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 11


Document Has Been Signed on 06/21/2024 12:10 PM - It Cannot Be Edited

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: SYCAMORE RESIDENTIAL CARE CENTER, B LLC
FACILITY NUMBER: 342700984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and temperature reading, the licensee did not comply with the section cited above in one of three residnet bathroom faucet had water at 140' F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
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Licensee will immediately post a sign at the sink to warn residents until water is within 105-120' F.

This to be cleared by POC visit.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in two of two staff training was not available for review. One staff stated they are behind in their training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
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Licensee will insure all staff training is up to date and available for LPA review.

LPA to clear POC by visit.
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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 11


Document Has Been Signed on 06/21/2024 12:10 PM - It Cannot Be Edited

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: SYCAMORE RESIDENTIAL CARE CENTER, B LLC
FACILITY NUMBER: 342700984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 5 of 6 residents had LIC 625s older that 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2024
Plan of Correction
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Licensee will notify LPA when reappraisals are complete and reviewed for signatures.
To be cleared by POC visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 11