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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701116
Report Date: 03/02/2023
Date Signed: 03/02/2023 04:39:45 PM


Document Has Been Signed on 03/02/2023 04:39 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:LAKEWOOD VILLAFACILITY NUMBER:
342701116
ADMINISTRATOR:QUIAMBAO, GLADYSFACILITY TYPE:
740
ADDRESS:8708 GERBER ROADTELEPHONE:
(925) 954-5329
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:18CENSUS: 16DATE:
03/02/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Dulce RosalesTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Pang Lee and Avelina Martinez arrived at the facility to conduct an unannounced post-licensing inspection on 03/02/2023. LPAs met with Dulce Rosales and explained the purpose of the visit. Dulce Rosales assisted with today’s visit.

LPAs inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, residents bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve 18 ambulatory, of which 9 may be non-ambulatory and 6 may be bedridden with hospice waiver for 3 residents. . LPAs observed the facility to be free of odor, clean and in good repair. LPAs observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present

LPAs observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured in resident bathroom. The water temperature measured at 132.3 degrees. Fire extinguishers, smoke and carbon monoxide detectors are in good repair. Facility thermostat observed at 72 degrees Fahrenheit. LPAs checked medication storage and found medication to be locked away and inaccessible to clients. Toxins were made un-accessible to clients in care.
First aid kit was complete. LPAs requested client and staff files for review. LPAs reviewed (1) resident file and (1) staff file. R1 file not was not complete it was missing appraisal needs and service plan.

Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
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 3


Document Has Been Signed on 03/02/2023 04:39 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: LAKEWOOD VILLA
FACILITY NUMBER: 342701116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2023
Section Cited

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87705(c)(5) Care of Persons with Dementia: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually...This requirement is not met as evidence by:
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Licensee will ensure that R1 has an assessemtent completed by POC date 03/16/2023. LPA Lee will clear POC by POC visit date.
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Based on observation and file review, the Licensee did not ensure R1 had a annual assessment/Needs and Service plan in their file. This posed a potential health and safety risk to R1.
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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-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: LAKEWOOD VILLA
FACILITY NUMBER: 342701116
VISIT DATE: 03/02/2023
NARRATIVE
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The facility has one main entry Covid-19 screening point, and has a Covid-19 mitigation plan. The facility has a 30 day supply of PPE, and conduct daily cleaning. The facility furniture is spaced six feet apart.

As a result of this post-licensing visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the 809 D page. Technical assistance was given for water temperature. An exit interview was conducted, and a copy of this 809 report, 809 D Page, TA and Appeals rights were provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3