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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701230
Report Date: 09/26/2023
Date Signed: 09/26/2023 10:40:44 AM


Document Has Been Signed on 09/26/2023 10:40 AM - 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 LIVINGFACILITY NUMBER:
342701230
ADMINISTRATOR:LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:6825 BENDER CTTELEPHONE:
(510) 710-5707
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY:6CENSUS: 4DATE:
09/26/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Salote LewisTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a plan of correction (POC) visit. LPA Moleski met with facility administrator Salote Lewis and explained the purpose of the visit.

LPA Moleski cited this facility on 8/21/23 after LPA Moleski learned that a resident (R1) did not have a medical assessment (LIC 602) completed within a year of admission. During that visit, LPA Moleski and Lewis agreed upon a plan of correction due date of 9/18/23. Lewis acquired a new LIC 602 on 9/21/23.

A civil penalty for failure to correct this deficiency is being assessed. The civil penalty for failure to correct this deficiency is $100 a day for three days, for a total of $300.

An exit interview was held and a copy of this report, along with a copy of the LIC 421FC generated for this civil penalty, was left with Salote.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
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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