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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701248
Report Date: 01/31/2024
Date Signed: 01/31/2024 11:50:57 AM


Document Has Been Signed on 01/31/2024 11:50 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 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: 6DATE:
01/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Misivono QadrokaTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Sacramento Senior Living II on 1/31/23 at 9:00am to conduct a case management deficiencies inspection to address additional deficiencies observed while conducting a complaint investigation.

Based on the interviews and statements obtained during a complaint investigation, two of the resident's interviewed confirmed that they could not wake a staff member with pages sent from the resident's bedroom following an incident where a resident fell in their room overnight. Residents attempted to page the staff member for assistance with no response and called 911 for assistance. Staff interview confirmed the events as described by residents. The requirements for basic services such as care and supervision were not met by the staff member present at the facility.

Additionally, when LPA Gould washed his hands he observed the water to be very hot. When the water temperature was tested a temperature of 136 degrees was recorded. LPA requested staff to turn down the hot water.

The following deficiency is cited per California Code of Regulations, Title 22.

Exit interview conducted and a copy of this report and appeal rights were left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/31/2024 11:50 AM - 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: 01/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2024
Section Cited
CCR
87464(f)(1)

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Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by statements from staff and residents that the staff member did
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facility will conduct additional training with staff and a written plan of correction that indicates the appropriate response time for assisting residents with care.
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not respond to resident pages when he sustained a fall at the facility which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
02/01/2024
Section Cited
CCR87303(e)(2)

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Maintenance and Operation: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature
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facility staff turned down the hot water temperature, Facility will provide a written plan of correction indicating how the facility will ensure the hot water temperature meets regulations and the frequency of hot water testing by facility staff on a regular basis.
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of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). this requirement was not met as evidenced by LPA testing of hot water temperature which poses an immediate health, safety or personal rights risk 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) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2