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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701248
Report Date: 08/07/2023
Date Signed: 08/07/2023 01:27:00 PM


Document Has Been Signed on 08/07/2023 01:27 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:
08/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Misivona QadrokaTIME COMPLETED:
01:40 PM
NARRATIVE
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On 08/07/2023 at 12:06 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to conduct a case management visit regarding a phone call on 08/02/2023 from Ombudsman, Suhair Siraj.

LPA was greeted by caregiver, Misivono Qadroka and explained the purpose for the visit.
The purpose of the visit is in regards to two learned incident that was called and reported to LPA Lee by ombudsman,Suhair Siraj, on 08/02/2023. It was learned that there were two separate incidents. One incident occurred on 06/02/2023 at 11:30 AM, regarding a knife that was brought to administrator Salote Lewis by a resident. The other incident occurred on 07/26/2023 at 8:30 AM, where a residents threw a steel water bottle at another resident's leg, causing redness with a red bumped. The two incidents was not reported to CCLD and the ombudsman's office. It was learned that the resident called ombudsman, Suhair Siraj to report the two incidents and ombudsman, Suhair Siraj then reported the two incidents to the department. LPA Lee spoke to administrator Salote Lewis on the phone and reminded her that all incidents needs to be reported to the department within seven days.

As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with caregiver Misivona Qadroka, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were 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: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023
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 08/07/2023 01:27 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: 08/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2023
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events…
(D) Any incident which threatens the welfare, safety, or health of any resident…
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Licensee agrees to review section 87211(a)(1)(D) and provide LPA Lee a written statement acknowledging the importance of sending incident reports and summarize her understanding of the regulation. Licensee agrees to email POC by POC date 08/14/2023 by 5:00 PM by end of day.
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Based on interviews, observations and records review, the licensee did not ensure two incidents were reported to the licensing agency or responsible parties. This poses a potential health, safety, and personal rights risks to residents in care.
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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: 08/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2