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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701338
Report Date: 08/13/2026
Date Signed: 08/13/2026 02:46:41 PM

Document Has Been Signed on 08/13/2026 02:46 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KEVINBERG CARE HOMEFACILITY NUMBER:
342701338
ADMINISTRATOR/
DIRECTOR:		PARAMO, FERNANDO PAZFACILITY TYPE:
740
ADDRESS:8351 LANCRAFT DR.TELEPHONE:
(916) 382-9472
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 4DATE:
08/13/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Fernanado Paz Paramo TIME VISIT/
INSPECTION COMPLETED:
03:01 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced on 08/13/2026 to conduct a case management visit. LPA Lee met with Administrator Fernando Paz Paramo and explained the purpose of the visit. A brief interview was conducted with Administrator Paramo.

The purpose of the visit was to follow up on deficiencies identified during complaint investigation control number 27-AS-20260428150655. During the investigation, it was learned that Resident 1 (R1) was admitted to the facility on 06/24/2023. Record review revealed that the facility did not have documentation demonstrating that a pre-admission appraisal was completed prior to R1's admission. R1's LIC 603A Resident Appraisal documented that R1 was in good health, did not use a wheelchair, and did not require assistance with transferring or turning in bed. The facility also did not have a Needs and Services Plan in place identifying R1's care and service needs. The investigation further revealed that R1 subsequently experienced changes in care needs. Administrator Paramo and Staff 1 (S1) acknowledged that R1's care needs had increased. Additionally, on 03/17/2026, the facility issued R1 a 30-day eviction notice stating that R1's “level of care is higher and needs more professional care,” further documenting the facility's awareness that R1's care needs had changed. However, record review revealed no documentation demonstrating that R1 was reappraised or that R1's appraisal and care needs were updated to reflect the change in condition, including changes associated with R1's hospitalization. Moreover, Administrator Paramo acknowledged that the pre-admission appraisal, Needs and Services Plan, reappraisal, and incident reports had not been completed and reported to CCLD.

CONTINUED LIC 809-C

Arielle Pascua
Pang Lee
DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2026
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 5
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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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: KEVINBERG CARE HOME
FACILITY NUMBER: 342701338
VISIT DATE: 08/13/2026
NARRATIVE
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During today's visit, LPA Lee provided Administrator Paramo the following forms and explained what the forms are used for:

1. LIC 603 Replacement Appraisal Information

2. LIC 603A Resident Appraisal

3. Resident Reappraisal

4. LIC 625 Needs and Service Plan

5. LIC 624 Incident Report ( LPA Lee provided Administrator Paramo CCLD's fax number and email for reporting)

6. An Examplet/Template of Progress Note/Charting Notes

Based on interviews conducted and records reviewed and obtained during the investigation, deficiencies were observed and cited pursuant to the California Code of Regulations, Title 22, and the California Health and Safety Code. The deficiencies are documented on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted with Administrator Paramo. A copy of the LIC 809, LIC 809-D, and appeal rights were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/13/2026 02:46 PM - It Cannot Be Edited


Created By: Pang Lee On 08/13/2026 at 01:00 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: KEVINBERG CARE HOME
FACILITY NUMBER: 342701338

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2026
Section Cited
CCR
87457(c)

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87457(c) Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria ...
This requirement was not met as evidenced by:
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The Administrator agrees to ensure that a pre-appraisal is completed prior to admitting any resident to the facility. The Administrator will review the regulation cited and submit a written statement to
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Based on record review and interviews, the Licensee did not ensure that R1 had a completed pre-appraisal prior to admission to the facility on 06/24/2023. This posed a potential health and safety risk to R1.

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LPA Lee confirming that the regulation has been reviewed and understood. POC is due by 08/27/2026 at 5:00 PM.
Type B
08/27/2026
Section Cited
CCR87467(a)

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87467(a) Resident Participation in Decision making
(a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility.

This requirement was not met as evidenced by:
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The Administrator agrees to ensure that a completed Needs and Services Plan is maintained for each resident in care. The Administrator will complete a Needs and Services Plan for all residents currently in care and email copies to LPA Lee.
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Based on record review and interviews, the Licensee did not ensure that R1 had a complete Needs and Services Plan in place. This posed a potential health and safety risk to R1.

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Additionally, the Administrator will review the regulation cited and submit a written statement to LPA Lee confirming that the regulation has been reviewed and understood. POC is due by 08/27/2026 at 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.
Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/13/2026 02:46 PM - It Cannot Be Edited


Created By: Pang Lee On 08/13/2026 at 01:06 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: KEVINBERG CARE HOME
FACILITY NUMBER: 342701338

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2026
Section Cited
CCR
87463(a)

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87463(a) Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.
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The Administrator agrees to ensure that a reappraisal is completed for each resident when there is a change in the resident’s condition. The Administrator will review the regulation cited and submit a written statement to LPA Lee
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This requirement was not met as evidenced by:
Based on record review and interviews, the Licensee did not ensure that a reappraisal was completed for R1 following a change in R1’s condition and being admitted to the hospital. This posed a potential health and safety risk to R1.
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confirming that the regulation has been reviewed and understood. POC is due by 08/27/2026 at 5:00 PM.
Type B
08/27/2026
Section Cited
CCR87211(a)(1)

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87211(a)(1) Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...
(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 specified in (A) through (D) below...
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The Administrator agrees to ensure that all required incident reports are completed and submitted to the Department and that residents’ responsible parties are notified as required.
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This requirement was not met as evidenced by:
Based on record review and interviews, the Licensee did not ensure that required incident reports were completed and submitted to the Department and that R1’s responsible party was notified when R1 was hospitalized, experienced a change in condition, and sustained pressure injuries. This posed a potential health and safety risk to R1.
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The Administrator will review the regulation cited and submit a written statement to LPA Lee confirming that the regulation has been reviewed and understood. POC is due by 08/27/2026 at 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.
Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2026


LIC809 (FAS) - (06/04)
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