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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701230
Report Date: 10/20/2023
Date Signed: 10/20/2023 03:10:53 PM


Document Has Been Signed on 10/20/2023 03:10 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: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:
10/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Dillon WilliamsTIME COMPLETED:
03:15 PM
NARRATIVE
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On 10/20/23 at 1:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a case management regarding an AWOL incident which occurred on 10/13/2023. LPA Lee met with direct care staff, Dillon Williams, who then called administrator, Salote Lewis to informed that Community Care Licensing Department (CCLD) is present in the facility. LPA Lee explained the purpose of the visit. The census is 4 resident with one facility staff. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

At 2:00 PM, LPA Lee toured the facility with direct care staff, Dillon Williams, to ensure the safety of the residents. LPA interviewed direct care staff, Dillon and reviewed incident report dated 10/16/2023. LPA Lee also reviewed (R1) LIC 625, Needs and Services and LIC 602 Physician's Report. Based on interview and record review it was determined that R1 exited the facility front door on 10/13/2023. Moreover, it was also learned that while staff 1 (S1) was doing rounds to check on the residents (S1) did not see (R1) in (R1) room or anywhere in the facility. Law enforcement was called, and a missing person report was filed.

R1's LIC 602, Physician Report dated 09/25/2023 was reviewed by LPA Lee and it revealed that (R1) is unable to leave the facility unassisted. Interview with Administrator revealed facility's internal plan includes providing supervision for R1 and all other residents in care. Additionally, it was revealed through interview that R1 left the facility, and no facility staff was aware of (R1) whereabouts. It was also discovered that (R1) was approximately 0.8 miles away from the facility when law enforcement found (R1) and brought (R1) back to the facility.

Based on today's case management, a citation is issued under Title 22, Division 6. An immediate civil penalty in the amount of $500 is issued in addition to citation due to absence of supervision. An exit interview was conducted with direct care staff, Dillon Williams. A copy of this report LIC 809, LIC 809-D and appeal rights was provided to direct care staff at the end of the visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
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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Document Has Been Signed on 12/06/2023 08:51 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/22/2023 07:26 PM

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: SACRAMENTO SENIOR LIVING
FACILITY NUMBER: 342701230

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2023
Section Cited
HSC
1569.312(d)

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1569.312(d)Basic services requirements: Being aware of the resident's general whereabouts, although the resident may travel independently in the community.

This requirement was not met as evidence by:
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Facility Administrator agrees to conduct elopement drill and training for all staff by POC date 10/18/2023. Facility Administrator will also submit a plan to ensure residents general whereabouts are known by staff.
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Based on file reviews and interviews, the Licensee did not ensure staff were aware of R1 general whereabouts as R1 was found by a law enforcement and returned R1 to the facility. This posed an immediate health and safety risk to R1.
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Plans to include , but not limited to: location within the facility and documentation to indicate when checks are completed. Facility administrator will email LPA Lee pang.lee@dss.ca.gov POC by POC due date 10/27/2023 by 5 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) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
LIC809 (FAS) - (06/04)
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