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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701251
Report Date: 03/19/2026
Date Signed: 03/19/2026 11:12:39 AM

Document Has Been Signed on 03/19/2026 11:12 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:SIERRA LOMA ASSISTED LIVINGFACILITY NUMBER:
342701251
ADMINISTRATOR/
DIRECTOR:		ILONA CORPUSFACILITY TYPE:
740
ADDRESS:3950 ANNADALE LANETELEPHONE:
(916) 489-6900
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 94CENSUS: 78DATE:
03/19/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Kyle Riley TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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An unannounced case management visit was conducted by the Licensing Program Analyst (LPA) Avelina Martinez on March 19, 2026, at 10:00 AM. LPA Martinez met with Kyle Riley and explain the purpose of the visit.

The purpose of the visit today, is in response to learned deficiencies. It was learned that resident 1 (R1) is legally blind, and requires reasonable accommodation. R1's was not provided a third party witness during the review of the admission agreement and facility documents. Based on interviews resident 1 (R1) was not fully informed of the documents they were signing. It was also learned facility staff 1 (S1) served as R1's witness, which is a conflict of interest. Additionally, facility staff accepted R1 at a basic Supplemental Security Income (SSI) income rate. However, R1 is being charged above their basic SSI income rate of $1,206.94 causing additional charges to R1. R1 accrues a balance of $213.13 each month.

As a result, of the above mentioned deficiencies the facility will be cited 1569.269 (a)(16) Enumerated rights; severability and 87464(e) Basic Services. The deficiencies can be found on the 809 D page.

An exit interview was conducted, and a copy of this 809 report, 809-D Page, and Appeal rights were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/19/2026 11:12 AM - It Cannot Be Edited


Created By: Avelina Martinez On 03/18/2026 at 05:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIERRA LOMA ASSISTED LIVING
FACILITY NUMBER: 342701251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2026
Section Cited
CCR
1569.269(a)(16)

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1569.269 (a)(16) Enumerated rights; severability: Residents of residential care facilities for the elderly shall have all of the following rights: reasonable accommodation of individual needs and preferences in all aspects of life in the facility...This requirement was not met as
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Facility staff agrees to review the admission agreement and resident fund management service document with R1. Facility staff agrees to invite a third party (Ombudsman) witness to the review of documents. By POC date 04/09/2026
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evidence by: Based on file review and interviews, the Licensee did not ensure R1 was provided a third party witness during the review of Admission Agreement and facility documents, causing R1 to not be fully informed of the admission agreement and facility documents. This posed a potential health and safety risk to R1.
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Type B
04/09/2026
Section Cited
CCR87464(e)

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87464(e) Basic Services: If the resident is an SSI/SSP recipient, then the basic services shall be provided and/or made available at the basic rate at no additional charge to the resident. This requirement was not met as evidence by: Based on file review and
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Facility staff agrees to review R1's SSI rate. Facility staff agrees to invite a third party (Ombudsman) witness to the SSI review with R1. By POC date 04/09/2026
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interviews, the Licensee did not ensure R1 was not charged above their basic SSI rate. This posed a potential health and safety risk to R1.
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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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2026


LIC809 (FAS) - (06/04)
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