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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701248
Report Date: 05/15/2024
Date Signed: 05/15/2024 03:28:34 PM


Document Has Been Signed on 05/15/2024 03:28 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 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:
05/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Salote LewisTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a case management visit on 5/15/2024. LPA met with Administrator Salote Lewis and stated the purpose of today’s visit.

The purpose of today's visit is in response to deficiencies observed during a complaint visit on 5/9/24. On 5/9/24, LPA observed a staff room with a bed; however, the facility sketch does not indicated that there is a staff room. Based on record review, it was learned that the room was initially designated as an office. The facility has converted the office into a staff room for the live-in staff without notifying the Department.

LPA informed the Administrator that if the facility chooses not to have a staff room, a plan of operation addendum shall be sent to Licensing indicating awake staff at all times.

Deficiencies were cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code.

An exit interview was conducted, a copy of this report, LIC 809-D and appeal rights were provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
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 05/15/2024 03:28 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: SACRAMENTO SENIOR LIVING II

FACILITY NUMBER: 342701248

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2024
Section Cited
CCR
87305(b)

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87305(b) Alterations to Existing Building or New Facilities: The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists.
This requirement is not met as evidence by:
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The Licensee shall read regulation 87305 and submit a signed declaration of understanding to LPA by POC due date.

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Based on the LPA's findings, the facility has converted the office into a staff room. The facility failed to submit the plan to licensing, which poses a potential Health, Safety risk to residents in care.
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The Administrator has removed the bed and no longer uses the room as a staff room.

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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) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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