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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701158
Report Date: 09/30/2025
Date Signed: 09/30/2025 01:19:35 PM

Document Has Been Signed on 09/30/2025 01:19 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:LIVING HOPE ONEFACILITY NUMBER:
342701158
ADMINISTRATOR/
DIRECTOR:		LIVINGSTONE, JACQUELINEFACILITY TYPE:
735
ADDRESS:4801 34TH STTELEPHONE:
(916) 745-5716
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY: 12CENSUS: 9DATE:
09/30/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Jacqueline LivingtoneTIME VISIT/
INSPECTION COMPLETED:
01:36 PM
NARRATIVE
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An unannounced case management visit was conducted at this facility today by Licensing Program Analyst (LPA) Pang Lee. Upon arrival, LPA Lee was greeted by House Manager Wei Ming Zeng, and the purpose of the visit was explained. The designated Administrator, Jacqueline Livingstone, arrived approximately 2 hours later and joined the visit. At the time of the visit, the facility's current census was 9.

The purpose of this quarterly visit was to follow up on items outlined during the informal conference held on 03/17/2025, which included the requirement for increased monitoring. The focus of this visit was to review the following areas of concern originally identified during the 03/17/2025 meeting:

· Care and supervision

· Personal rights

· Fire clearance

· Administrator’s qualifications and duties

· Plan of Corrections (POC)

· Adherence to approved facility sketch

CONTINUED LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: LIVING HOPE ONE
FACILITY NUMBER: 342701158
VISIT DATE: 09/30/2025
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· Staff training on Ombudsman and Community Care Licensing (CCL) responsibilities

· Modifications and alterations to the facility grounds

This facility is licensed as an Adult Residential Facility and is approved to serve a maximum of 12 ambulatory clients. During the visit, LPA Lee conducted an inspection of the physical plant, including but not limited to the common areas, kitchen, dining area, client bedrooms, bathrooms, laundry room, and outdoor courtyards. The facility was observed to be clean, free of odors, and in good repair. All client bedrooms were properly furnished with appropriate bedding and adequate lighting. The layout of the facility was not consistent with the original facility sketch that had been approved during the licensure process. During a case management visit on 06/04/2025 LPA Lee informed administrator Livingston that until the LIC 850 has been approved by the fire department the facility needs to adhere to the original facility floor plan. As of today, the front office of the facility and resident bedroom 7 was not switched back to the original approved fire clearance. Administrator Livingstone stated that she will ensure that the office and client’s room are switched back to the original floor plan by end of today 09/30/2025 5:00 PM end of day. In the client bathroom, the hot water temperature was measured at 106.9 degrees Fahrenheit, which falls within the required regulatory range of 105 to 120 degrees Fahrenheit.

Smoke and carbon monoxide detectors were tested and found to be functioning and in compliance with fire safety regulations. The fire extinguisher was located in common area, hallway of the facility and in the back of the facility and had last been serviced on 12/12/2024. The facility’s last fire drill was conducted on 09/18/2025. LPA Lee also observed that the facility had a public telephone located in the common area. LPA Lee observed that the Ombudsman poster was displayed inside the staff office. Administrator Livingstone was advised to relocate the poster to an area visible to clients. LPA Lee also advised that the facility’s licensing poster be posted in a clearly visible and accessible location. During the inspection, the thermostat was found to be functioning properly and displayed a temperature of 71°F. Toxic cleaning supplies were observed stored in a locked storage closet, making them inaccessible to clients. Additionally, sharp kitchen knives were locked in the kitchen and were also inaccessible to clients. It was observed that Staff 1 (S1) was present at the facility for training, and it was S1’s first day on-site. LPA Lee observed S1 mopping the floor and preparing lunch for clients.

CONTINUED LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC809 (FAS) - (06/04)
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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: LIVING HOPE ONE
FACILITY NUMBER: 342701158
VISIT DATE: 09/30/2025
NARRATIVE
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S1 was seen chopping onions directly on the kitchen counter, at which point House Manager Zeng provided a cutting board for proper food preparation. LPA Lee also verified the food supply, confirming that the facility maintained at least a two-day supply of perishable food items and a seven-day supply of nonperishable items, in accordance with Title 22 regulations. Furthermore, it was reported that a volunteer staff member (S2) is currently residing in a room at the back of the facility. According to Administrator Livingstone, S2 assists with general cleaning and chores but does not provide any care or supervision to clients and is being supervised by House Manager Zeng who also resides in the back of facility. It was observed that the clients that were housed in the back of the facility without fire clearance approved have been moved to the front of the facility where the bedrooms are fire cleared for clients.

The medication storage area was reviewed and found to be locked and secure. Staff records reviewed were incomplete. S1 did not have health screening and a TB test as well as a S1 did not have a file in the facility prior to S1’s first day on the job. Record reviews showed that S1 and S2 are fingerprints clear and associated with the facility. LPA Lee reviewed 7 out of 9 client files and they were incomplete. 7 client files LIC 625 was observed to be in their file; however, the document was left blank and signed by the administrator and client. The first aid kit was checked and contained all required supplies.

It is noted that on 04/10/2025, the Licensee participated in a Technical Support Program (TSP) summary meeting. During this meeting, general resources were provided to assist the facility in improving compliance. The Licensee agreed to utilize these resources, which included a TSP PowerPoint presentation.

As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. Civil penalties assessments were also cited for immediate and repeat violations. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, LIC 421IM, LIC 421FC and Appeals rights were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/30/2025 01:19 PM - It Cannot Be Edited


Created By: Pang Lee On 09/30/2025 at 12:57 PM
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: LIVING HOPE ONE
FACILITY NUMBER: 342701158

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2025
Section Cited
CCR
80076(a)(13)

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80076 Food Services
(a) In facilities providing meals to clients, the following shall apply:
(13) All persons engaged in food preparation and service shall observe personal hygiene...
This requirement is not met as evidenced by:

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Administrator agrees to conduct training on food services for facility staff. Documents of training materials used, sign in sheets and a statement of acknowledgement of understanding of the regulation will be provided to LPA Lee by 10/10/2025 end of day 5:00 PM
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Based on observation S1 was seen chopping onions directly on the kitchen counter, at which point House Manager Zeng provided a cutting board for proper food preparation, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
10/10/2025
Section Cited
CCR80020(a)(1)

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80020 Fire Clearance
(a) All facilities shall be secure and maintain a fire clearance approved by the city or county fire department...
(1) The request for fire clearance shall be made through and maintained by the licensing agency.

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 Administrator Livingstone stated that she will ensure that the office and client’s room are switched back to the original floor plan by end of today 09/30/2025 5:00 PM end of day. A statement of acknowledgement of understanding of the regulation cited and POC due by 10/10/25 at the end of day 5:00 PM.



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Based on observations, interviews and record review, the licensee did not adhere to the approved fire clearance and facility sketch by housing two clients in the front office and turning the room in the front of the facility to a staff office without approval and notifying CCLD.
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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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/30/2025 01:19 PM - It Cannot Be Edited


Created By: Pang Lee On 09/30/2025 at 01:01 PM
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: LIVING HOPE ONE
FACILITY NUMBER: 342701158

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2025
Section Cited
CCR
85068.2(b)

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85068.2 Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include:
This requirement is not met as evidenced by:
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Administrator will review client files and complete LIC 625 Needs and Services Plan. A statement of acknowledgement of understanding of the regulation along with the 7 residents LIC 625 will be emailed to LPA Lee. POC is due on 10/10/25 at the end of day 5:00 PM.

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Based on record review 7 out of 9 clients file was missing LIC 625 was incomplete and left blank but signed by administrator and clients in care. This posed a potential 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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
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