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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701248
Report Date: 03/06/2023
Date Signed: 05/23/2023 04:14:46 PM


Document Has Been Signed on 05/23/2023 04:14 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 IIFACILITY NUMBER:
342701248
ADMINISTRATOR:LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:34 LOMA MAR CTTELEPHONE:
(530) 710-5707
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
03/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Clearaptra and Salote (Charlotte) LewisTIME COMPLETED:
03:35 PM
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Licensing Program Analysts (LPA) Pang Lee and Licensing Program Manager (LPM) Czarrina Camilon Lee arrived unannounced to conduct a Pre-Licensing change of ownership (CHOW) Inspection of the facility to ensure compliance with Title 22 regulations. Upon arrival LPA Lee and LPM observed the primary exit gate and it was locked. LPA Lee and LPM Czarrina observed care giver removing the lock to the gate. LPA Lee and LPM Czarrina met with Clearaptra Gardiner and Salote Lewis and explained the purpose of today's visit.

Facility has a fire clearance for 6 non-ambulatory residents. Administrator, Salote Lewis will be the Administrator of this facility. Salote Lewis holds current administrator certificate # 6062098740 which will expire on 08/08/2024. LPA Lee and LPM Czarrnia inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and the kitchen. Resident bedrooms were furnished, and resident bathrooms were in good repair. LPA observed required furniture and lighting throughout the facility. The first aid kit observed to be complete. LPA Lee observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. The facility smoke detectors, carbon detectors, and fire extinguishers are in good repair. The facility has an adequate of utensils, seven-day non-perishable and two-day perishable food supplies. The water temperature measured at 108.3 degrees, and the facility temperature was 73 degrees. LPA Lee observed the pantry along with the refrigerator to be locked. LPA observed the pantry door lock being switch to a unlock door knob which will make it easily accessible to residents. LPA Lee observed caregiver removed the lock to the refrigerator. LPA Lee observed staff and resident files to be locked and readily available for review. The facility had Covid-19 posting throughout the facility. The facility had a infection control plan completed and provided it to Licensing for approval.

Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2023
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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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 II
FACILITY NUMBER: 342701248
VISIT DATE: 03/06/2023
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The facility had one central entry point, and the facility had routine symptom screening checks for residents, staff, and visitors. The facility had a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented.

Based on a review of this facility during this Pre-licensing visit, it was determined that this facility was found to be in compliance at this time. The applicant has passed the pre-licensing component III of the application process. LPA Lee will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. An exit interview was conducted, and a copy of this report has been provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
LIC809 (FAS) - (06/04)
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