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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701161
Report Date: 11/28/2022
Date Signed: 11/28/2022 12:44:03 PM


Document Has Been Signed on 11/28/2022 12:44 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:MARCONI VILLAFACILITY NUMBER:
342701161
ADMINISTRATOR:DHANOA, MANPREETFACILITY TYPE:
740
ADDRESS:2100 MARCONI AVENUETELEPHONE:
(916) 571-5270
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 4DATE:
11/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Manpreet DhanoaTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 11/28/2022 at 9:00 AM to conduct a case management, LPA Martinez met with Manpreet Dhanoa explained the purpose of the visit.

The purpose of the visit today, is in response to learned deficiencies during a complaint investigation. LPA Martinez toured the facility on November 17, 2022 and November 28, 2022. During these visit, LPA Martinez observed that residents' rooms were not cleaned. LPA Martinez observed dead pest on window sils, unsanitary floors, and bed sheets missing. As a result it was determined the facility was unsanitary.

Moreover, the facility has Administrator changes pending. LPA Martinez Requested the following documents:

LIC 200 Facility Application


LIC 501: Personnel Record and Application
LIC 503: Health Screening
LIC 500: Personnel Work Schedule

All Administrator documents shall be emailed to LPA Martinez by December 2, 2022 by close of business 5PM.

As a result of this visit, the following deficiency was cited, per Title 22 Regulations. The deficiencies were cited on 809-D. An exit interview was conducted, and a copy of this 809 report, 809D Page, and Appeals Rights were given to facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022
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 11/28/2022 12:44 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: MARCONI VILLA
FACILITY NUMBER: 342701161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2022
Section Cited

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87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times...This requirement was not met as evidence by. Based on observation, the facility floors and window sils were unsanitary. This posed a potential health and safety 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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022
LIC809 (FAS) - (06/04)
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