Community Care Licensing

Document Has Been Signed on 08/02/2023 10:09 AM - It Cannot Be Edited

FACILITY NAME:	J. NAGTALON ADULT CARE SERVICES II		FACILITY NUMBER:	342701031
ADMINISTRATOR:	WANDASAN, JUDITH		FACILITY TYPE:	735
ADDRESS:	8155 SAINT BRENDAN PLACE		TELEPHONE:	(916) 524-2717
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95829
CAPACITY: 4		CENSUS: 4	DATE:	08/01/2023
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	01:52 PM
MET WITH:	Perlita Agcaoila		TIME COMPLETED:	03:23 PM

NARRATIVE

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LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the complaint investigation conducted on 06/22/2023 . LPA toured the facility, reviewed document submitted for plans of correction observed that the deficiencies cited on 06/22/2023 have been cleared. Section Cited: 80072(a)(1-3) Date Due: 06/22/2023 Plan of Correction: Administrator will conduct an in-service training for staff regarding understanding of personal rights for client care and supervision. Corrections: Cleared By Visit Clearance Date: 08/01/2023 Deficiency cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POC by POC due date. Facility was provided POC cleared letter. Exit interview conducted.

SUPERVISORS NAME: Stephenie Doub LICENSING EVALUATOR NAME: Albert Johnson LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023