342701230-8-21-2023-27-AS-VMOI-CUWRJN-20230821130413

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701230
Report Date: 08/21/2023
Date Signed: 08/21/2023 01:04:24 PM

Document Has Been Signed on 08/21/2023 01:04 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:	SACRAMENTO SENIOR LIVING		FACILITY NUMBER:	342701230
ADMINISTRATOR:	LEWIS, SALOTE		FACILITY TYPE:	740
ADDRESS:	6825 BENDER CT		TELEPHONE:	(510) 710-5707
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95820
CAPACITY:	6	CENSUS: 2	DATE:	08/21/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Salote Lewis		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a postlicensing inspection. LPA Moleski met with facility administrator Salote Lewis and explained the purpose of the visit. LPA Moleski reviewed Lewis' file, a staff member's file (S1) and two resident files (R1-R2). This facility currently has two residents. R1 is age 75. R2 is age 34. Less than 75 percent of this facility's residents are over the age of 60. R1 was admitted on 8/8/23, according to R1's admission agreement. R1's admission agreement was not signed by R1 or a responsible party as of this visit date. R1's LIC 602 is dated 7/1/2022, which is more than a year prior to admission. R1's Identification and Emergency Information form is blank and is unsigned, and therefore did not contain a name, address, or phone number of a physician and dentist to be called in an emergency. Lewis said she had not received completed and signed documents back from R1's conservator. While reviewing medication administration records (MARs), LPA Moleski observed two missed doses for R1. R1 did not receive a nighttime dose of one medication on 8/8/23, and did not receive a midday dose of a different medication on 8/17/23, according to the MARs. LPA Moleski toured the facility with Lewis and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 70 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 116 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. [continued on 809-C]

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023

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 6

Document Has Been Signed on 08/21/2023 01:04 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: SACRAMENTO SENIOR LIVING	FACILITY NUMBER: 342701230
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87101(r)(5)

"(5) 'Residential Care Facility for the Elderly' means a housing arrangement chosen voluntarily by the resident, the resident's guardian, conservator or other responsible person; where 75 percent of the residents are sixty years of age or older and where varying levels of care and supervision are provided, as agreed to at time of admission or as determined necessary at subsequent times of reappraisal. Any younger residents must have needs compatible with other residents." This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of resident records, the licensee did not ensure 75 percent of residents were aged 60 or older, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/25/2023
	Plan of Correction
1 2 3 4	Licensee agrees to write a statement acknowledging the section above, and that the next two residents admitted will be age 60 or over, and that the minimum 75 percent threshold shall be maintained heretofore. Licensee further agrees to send LPA Moleski a copy of this statement. vincent.moleski@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

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: SACRAMENTO SENIOR LIVING	FACILITY NUMBER: 342701230
	VISIT DATE: 08/21/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

While inspecting a facility bathroom, LPA Moleski and Lewis observed a bottle of toilet bowl cleaner left in an unlocked cabinet. While inspecting the backyard, LPA Moleski and Lewis observed an unlocked shed containing unsecured cans of paint and bags of drywall joint compound.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked closet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed one staff member (S1) and two residents (R1-R2).

This facility is being cited per the applicable 22 CCR Sections. An exit interview was held with Lewis. Appeal rights and a copy of this report were left with Lewis.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 08/21/2023 01:04 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: SACRAMENTO SENIOR LIVING	FACILITY NUMBER: 342701230
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not ensure cleaning solutions, paint and drywall joint compound were inaccessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2023
	Plan of Correction
1 2 3 4	Licensee locked up the materials during this visit. This POC will be cleared.

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of R1's MARs, the licensee did not ensure doses were given as prescribed, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2023
	Plan of Correction
1 2 3 4	Licensee agrees to conduct a staff training on medication administration procedures. Licensee further agrees to send LPA Moleski a copy of a sign-in sheet. vincent.moleski@dss.ca.gov

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 08/21/2023 01:04 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: SACRAMENTO SENIOR LIVING	FACILITY NUMBER: 342701230
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)(9)

Resident Records

(b) Each resident's record shall contain at least the following information: (9) Name, address and telephone number of physician and dentist to be called in an emergency. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of R1's file, the licensee did not ensure the above documentation was completed, signed, and kept on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2023
	Plan of Correction
1 2 3 4	Licensee agrees to acquire completed and signed documentation as described above by the POC due date. Licensee agrees to send LPA Moleski a copy of this documentation. vincent.moleski@dss.ca.gov

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of R1's file, the licensee did not ensure the above documentation was completed, signed, and kept on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2023
	Plan of Correction
1 2 3 4	Licensee agrees to acquire completed and signed documentation as described above by the POC due date. Licensee agrees to send LPA Moleski a copy of this documentation. vincent.moleski@dss.ca.gov

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 08/21/2023 01:04 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: SACRAMENTO SENIOR LIVING	FACILITY NUMBER: 342701230
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of R1's file, the licensee did not ensure the above documentation was completed, signed, and kept on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2023
	Plan of Correction
1 2 3 4	Licensee agrees to acquire completed and signed documentation as described above by the POC due date. Licensee agrees to send LPA Moleski a copy of this documentation. vincent.moleski@dss.ca.gov

Type B

Section Cited

CCR

87468(b)(1)(A)

Personal Rights of Residents

(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of R1's file, the licensee did not ensure the above documentation was completed, signed, and kept on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2023
	Plan of Correction
1 2 3 4	Licensee agrees to acquire completed and signed documentation as described above by the POC due date. Licensee agrees to send LPA Moleski a copy of this documentation. vincent.moleski@dss.ca.gov

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023

LIC809 (FAS) - (06/04)

Page: 6 of 6