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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701116
Report Date: 09/18/2024
Date Signed: 09/18/2024 01:31:07 PM


Document Has Been Signed on 09/18/2024 01:31 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:LAKEWOOD VILLAFACILITY NUMBER:
342701116
ADMINISTRATOR:QUIAMBAO, GLADYSFACILITY TYPE:
740
ADDRESS:8708 GERBER ROADTELEPHONE:
(925) 954-5329
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:18CENSUS: 13DATE:
09/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Gladys QuiambaoTIME COMPLETED:
01:33 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced on 09/18/2023 at 12:30 PM to conduct a case management visit. LPA Lee met with administrator Gladys Quiambao and explained the purpose of the visit and the deficiencies observed on 09/18/2024.

The purpose of the visit is to follow up on deficiencies learned during complaint investigation control number # 27-AS-20240912145951. Through the complaint investigation, it was learned that two staff are working and shadowing other facility staff without being associated to the facility. It was learned that the two staff are fingerprint clear. It was also learned that staff 1 (S1) started working on 09/17/2024 and (S2) started working on 09/16/2024. During today’s visit the administrator associated (S1) and was not able to associate (S2). LPA observe administrator sending (S2) home.

The following deficiency were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiency can be found on the 809-D page. An exit interview was conducted, and a copy of the 809 report, 809-D page, LIC 421BG and appeal rights were given to the facility.


SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
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 09/18/2024 01:31 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: LAKEWOOD VILLA
FACILITY NUMBER: 342701116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2024
Section Cited
CCR
87355(c)

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87355 Criminal Record Clearance
(c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department:

This requirement is not met as evidenced by:
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Administrator will review the regulation cited 87355 and provided LPA Lee a statement of acknowledgment of the regulation being reviewed and understood. POC will be emailed to LPA Lee by POC date 09/23/2024 end of day.
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Based on interviews and records review, the facility did not comply with section cited above. The administrator had two new employees working without ensuring that the individuals are associated to the facility. This posed an immediate health and safety risk to the resident in care.
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During today’s visit administrator was able to associate (S1) and not (S2). (S2) was then sent home. Administrator will ensure to associate (S2) and provide LPA Lee a copy of (S2) being associated to the facility by POC date 09/23/2024 end of day 5:00 PM.

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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) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
LIC809 (FAS) - (06/04)
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