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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701364
Report Date: 02/07/2025
Date Signed: 02/07/2025 04:32:35 PM

Document Has Been Signed on 02/07/2025 04:32 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:WATERVIEW RESIDENCEFACILITY NUMBER:
342701364
ADMINISTRATOR/
DIRECTOR:		VIZCARRA, RHAYMONDFACILITY TYPE:
740
ADDRESS:6855 WATERVIEW WAYTELEPHONE:
(650) 303-2522
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 5DATE:
02/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Aeleah McDonaldTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 2/7/25 at 1:20pm Licensing Program Analysts (LPAs) Kevin Gould and Cynthia Tamayo arrived at Waterview Residence RCFE for the purpose of conducting a required 1 year annual inspection. LPA met with Licensee, Aeleah McDonald and together conducted a tour of the home.

LPAs and Licensee evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPAs observed the facility to be free of odor, clean and in good repair. LPAs observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.
LPAs observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPAs notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPAs observed centrally stored medications secure from residents.

LPAs conducted file for three residents and three staff members. LPAs observed resident file are in need of organization and observed two of the three resident files reviewed no personal rights forms were observed or singed by resident or authorized representatives. Additionally, LPAs requested three employee files to review and were unable to review because the files are being stored at another facility. LPAs were unable to verify staff records or training. LPA's were able to review one staff file who did not have a completed health screening form or verified TB test. LPAs observed staff member (S2) did have a criminal record clearance but was not associated to the facility prior to today's inspection.

Report Continued on LIC 9099-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: WATERVIEW RESIDENCE
FACILITY NUMBER: 342701364
VISIT DATE: 02/07/2025
NARRATIVE
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LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 9020 client roster and current administrator certificate.

Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/07/2025 04:32 PM - It Cannot Be Edited


Created By: Kevin Gould On 02/07/2025 at 04:08 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: WATERVIEW RESIDENCE
FACILITY NUMBER: 342701364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff record review, the licensee did not comply with the section cited above in one out of one staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Licensee has agreed to have the staff member complete the TB and health screening by the POC due date of 2/21/25

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-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/07/2025 04:32 PM - It Cannot Be Edited


Created By: Kevin Gould On 02/07/2025 at 04:08 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: WATERVIEW RESIDENCE
FACILITY NUMBER: 342701364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above in 3 out of 3 staff files LPA requested to review were not present at the facility and stored at another facility resulting in LPAs being unable to review all staff records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Licensee has agreed to ensure all staff files are complete, well organized and present at the facility for the department to review by the POC due date of 2/21/25
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of fingerprint cleared and associated staff, the licensee did not comply with the section cited above in one out of two staff members present at the facility which was not associated to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Staff member was associated to the facility while LPAs were present.
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-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 02/07/2025 04:32 PM - It Cannot Be Edited


Created By: Kevin Gould On 02/07/2025 at 04:08 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: WATERVIEW RESIDENCE
FACILITY NUMBER: 342701364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)(1)(A)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on resident file review, the licensee did not comply with the section cited above in two out of three resident files did not contain a signed personal rights form LIC 613c which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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LIcensee agrees for all resident files to be complete and well organized by the POC due date 2/21/25
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2025


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