342701248-6-29-2023-27-AS-PLEE-CT9NU3-20230629104541

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701248
Report Date: 06/29/2023
Date Signed: 06/29/2023 10:45:46 AM

Document Has Been Signed on 06/29/2023 10:45 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 LIVING II		FACILITY NUMBER:	342701248
ADMINISTRATOR:	LEWIS, SALOTE		FACILITY TYPE:	740
ADDRESS:	34 LOMA MAR CT		TELEPHONE:	(530) 710-5707
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	6	CENSUS: 6	DATE:	06/29/2023
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Lewis Salote		TIME COMPLETED:	11:00 AM

NARRATIVE

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Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 06/29/2023 at 9:00 AM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee were greeted by staff member, Misivono Qadroka and asked to call the Facility Designated Administrator, Lewis Salote to let her know that CCL was present at this time. Administrator Lewis Salote later joined the visit. Current Census was 6. LPA explained the purpose of the visit. The purpose of this visit is to follow-up on a plan of correction that were due 06/23/2023. During today's visit, LPA reviewed residents and staff files and they were complete. LPA Lee toured and inspected the facility to ensure deficiency previously cited on 06/13/2023 have been corrected.

LPA 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.
Based upon this inspection, LPA Lee observed the following:
1. Deficiency cited under Title 22 Regulation 87465(a)) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee.
2. Deficiency cited under Title 22 Regulation 87309(a) has been cleared. Licensee complied with the terms of the POC by POC due date.
3. Deficiency cited under Title 22 Regulation 87411(g)(2) has been cleared. Licensee did complied with the terms of the POC by POC due date.

4. Deficiency cited under Title 22 Regulation 87303(a) has been cleared. Licensee did complied with the terms of the POC by POC due date.

5. Deficiency cited under Title 22 Regulation 87412(a) has been cleared. Licensee did complied with the terms of the POC by POC due date.

Continued LIC 809C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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: 06/29/2023

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6. Deficiency cited under Title 22 Regulation 87412(c) has been cleared. Licensee did complied with the terms of the POC by POC due date.

7. Deficiency cited under Title 22 Regulation 87506(a) has been cleared. Licensee did complied with the terms of the POC by POC due date.

Proof of correction was submitted by email on 06/16/2023. Licensee complied with the terms of the POC by POC due date. Facility was provided with POC cleared letter. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC809 (FAS) - (06/04)

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