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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701248
Report Date: 06/13/2023
Date Signed: 06/13/2023 04:23:45 PM


Document Has Been Signed on 06/13/2023 04:23 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: 6DATE:
06/13/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Salote LewisTIME COMPLETED:
04:45 PM
NARRATIVE
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On 06/13/23 at 8:05 AM, Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced to conduct a post-licensing inspection. LPA Lee met with care staff Misivono Qadroka, who then called Licensee/Administrator to informed that CCL is here for a post-licensing visit. Licensee/Administrator Salote Lewis then arrived at the facility. LPA Lee explained the purpose of the visit. Administrator Certificate # 6062098740 expires 08/08/2024. There are currently 6 residents living at this facility.

LPA Lee toured and inspected the physical plant inside and outside with administrator to ensure there were no health and safety concerns. LPA Lee observed the front of the building not in good repair. LPA Lee observed the exterior of the home in the from is chipping with a hole. LPA Lee observed the kitchen, bedrooms, bathrooms, and common area. LPA Lee observed the dining table not in good repair. The dining table is not balance and is broken. LPA Lee observed sufficient furniture and lighting throughout the facility. LPA Lee observed the rooms to be clan and organized with comfortable furnishings. The hot water temperature was measured at 119.1 degrees Fahrenheit, which is within the required regulations of 105-120 degrees Fahrenheit . The temperature inside the facility measured at 72 degrees Fahrenheit, which is also within the required range of 68-85 degrees Fahrenheit.

LPA Lee observed sufficient seven-day non-perishable and two-day perishable food supplies. Fire extinguishers, smoke and carbon monoxide detectors are in good repair. Fire extinguisher was last serviced on 09/21/2022. LPA Lee checked medication storage and found medication to be locked away and inaccessible to clients. LPA Lee observed chemical toxin made accessible to residents in care. Toxin are kept in the laundry cabinet which is not lock; however the door to the laundry was kept opened and unlock. First aid kit was checked and is complete.

Continued on 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: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023
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: 06/13/2023
NARRATIVE
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LPA Lee reviewed 6 out of 6 medication administration record (MAR) and 1 out 6 MARs was complete. LPA Lee requested client and staff files for review. LPA Lee reviewed 6 out of 6 residents files and 6 out of 6 residents files were not complete. LPA Lee also reviewed 3 out of 3 staff files and 3 out of 3 staff files were not complete. LPA Lee reviewed staff criminal record clearances and association and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared but is not associated to the facility.

As a result of this Post-Licensing visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC-809 D page. Immediate Civil Penalty were assessed. An exit interview was conducted, and a copy of these LIC-809 reports, LIC 809-D page, LIC-421BG, and Appeals rights were provided to the Licensee/Administrator.



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

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/13/2023 04:23 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 II
FACILITY NUMBER: 342701248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Licensee did not ensure 3 out of 3 staff had first aid and CPR training. 3 out of 3 staff files had no documentation of current trainings, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
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Licensee agrees to conduct first aid and CPR trainings for all staff. Licensee also agrees to conduct required medical trainings to all staff. Licensee will email training materials/documents along with staff sign in sheet to LPA Lee by POC 06/23/2023 by 5:00 PM.
Type A
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review 6 out of 6 resident files were not complete. Files were missing documents. Some documents were signed, but was not filled out. Documents was also signed by licensee, but not signed by residents. Some documents had a different facility name that does not align with this facility. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
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Licensee agrees to review resident files and complete the blank documents. Licensee also agrees to go over the documents with the residents/family members and have those documents signed. Licensee agrees to review the regulations and submit a statement acknowledging that licensing have read and understood the regulations by POC date 06/23/2023 by 5:00 PM. LPA will complete a POC visit.
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: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 06/13/2023 04:23 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 II
FACILITY NUMBER: 342701248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The licensee did not ensure the outside exterior was in good repair. The exterior wood is chipping and has a hole. The licensee also did not ensure the dining table was in good repair. The dining table is not balance and is broken, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
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Licensee agrees to have the exterior hole repair and the dining table repair by POC date 06/23/2023 by 5:00 PM. Licensee will email POC to LPA Lee by POC date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above. The licensee did not ensure 3 out of 3 staff files are complete, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
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Licensee agrees to complete all staff files. Licensee also agrees to review regulations and write a statement acknowledging licensee understood regulations and documents that needs to stay in the staff files.
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: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 06/13/2023 04:23 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 II
FACILITY NUMBER: 342701248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where in accessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on obserview, the licensee did not comply with the section cited above. The licensee did not ensure the chemical cabinet was made inaccessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
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Licensee will purchase a lock and installed for the chemical cabinets by POC date 06/16/2023 by 5:00 PM. Licensee will send proof of POC to LPA Lee by POC due date.
Type A
Section Cited
CCR
87411(g)(2)
87411(g)(2) Personnel Requirements-General
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to criminal record review shall:
(2) Request a transfer for a criminal record clearance as specified in section.......

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Licensee did not ensure staff 1 was associated to the facility prior to working at the facility. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2023
Plan of Correction
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During the visit, Licensee called CCL to have staff 1 associated to the facility. Licensee stated that CCL technician stated it will take two business days to have S1 associated in the system. Licensee will email proof of LIC 9182 that Licensee emailed to CCL to have S1 associated. Licensee will send POC to LPA Lee by POC date 06/16/2023 by 5:00 PM.
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: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 06/13/2023 04:23 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 II
FACILITY NUMBER: 342701248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)
A plan for incidental medical and ental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for aswsistance in obtaining such care, by compliance with...

This requirement is not met as evidenced by:
The Licensee did not ensure 5 out of 6 residents MAR sheet was maintained. MAR section was not initialed, and it is unknown if medication were administered per care staff. This posed a immediate health and staff rish to residents in care.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Licensee did not ensure 5 out of 6 resident MAR shees was maintained. MAR section was not initial and it is unknown if medication were administer to resident, which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 06/23/2023
Plan of Correction
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Licensee agrees to conduct incidental medcial and dental training for all staff by POC date 06/23/2023 by 5:00 PM. Licensee agrees to email training documents along with staff signature to LPA Lee by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6