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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701364
Report Date: 04/21/2026
Date Signed: 05/07/2026 01:26:50 PM

Document Has Been Signed on 05/07/2026 01:26 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:
04/21/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Kevin Valino and Aeleah VizcarraTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On April 21, 2026 at 9:30 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Kevin Valino and Aeleah Vizcarra and explained the purpose of today's visit.

LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate and expires on 11/24/2027. During today's inspection LPA Martinez learned that the facility did not have a current administrator certificate posted in the facility. Facility staff will post the updated administrator certificate.

The facility is licensed for six non-ambulatory clients, which one can be bedridden (bedroom 1). There are currently five residents who reside at this facility. The facility has an approved hospice waiver for three.

The LPA Martinez toured the facility with the Kevin Hans Valino on April 21, 2026.

Facility staff 2 (S2) was not able to provide copies of the following documents natural disaster and infection control plan. The facility did not have a fire drill log, and two fire extinguishers did not have service tags. The fire extinguishers also did not have a purchase receipt. In addition, during the facility inspection, LPA Martinez observed that cleaning supplies were made accessible to residents in care. LPA Martinez also observed a mop bucket filled with water in the bathroom walk in shower.

Continued...

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2026
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 9
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: WATERVIEW RESIDENCE
FACILITY NUMBER: 342701364
VISIT DATE: 04/21/2026
NARRATIVE
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LPA Martinez also observed that the following food items did not have expiration dates and not sealed properly: strawberries with frost bite, salad dressing bottle, and marinated chicken in a food container. LPA Martinez reviewed three resident files, and all three files were missing reappraisals. LPA Martinez reviewed three staff files. Staff 2 (S2) did not have the following documents: a current first aid certificate and LIC 503 health screening. Staff files did not included 2026 staff training documentation. The facility did not have incident reporting binder. LPA Martinez will return at a late date to complete a medication inspection.

An immediate civil penalty of $500.00 is hereby assessed on April 21, 2026, for 87203 Fire Safety violation.
Based on today's inspection, an informal conference will be scheduled, and LPA Martinez will advise the Licensee of informal conference date and time.

As a result of this annual inspection visit, deficiencies were cited, per California Code of Regulations, Title 22 and Health and Safety Code and can be found on the 809-D pages. An exit interview conducted, and a copy of the 809 report, 809D-Page, LIC421M, and appeals right were given to the facility at the end of this visit.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 05/07/2026 01:26 PM - It Cannot Be Edited


Created By: Avelina Martinez On 04/21/2026 at 01:45 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: 04/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements 87211(a)(1)

This requirement is not met as evidenced by: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: 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...
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. The Licensee did not ensure the facility staff were submitting incident reports to the licensing agency. The facility also was not to provide incident reports during today's inspection, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2026
Plan of Correction
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Facility staff agrees to train all staff on Reporting Requirements and completing LIC 624 unusual incident report form by POC Date 05/12/2026. Facility staff agrees to email training documentation to LPA Martinez by 05/12/2026 by 5:00 PM.
Type B
Section Cited
HSC
1569.625(b)(2)
1569.625(b)(2) Staff training; legislative findings; contents :The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training....

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) (interview) (record review), the licensee did not comply with the section cited above three staff did not have 2026 training documentation, and staff 3 reported they have not received any training this year. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2026
Plan of Correction
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Facility staff agrees to start conducting annual training for all facility staff starting 04/28/2026. Facility staff will email training topics, training schedule dates, and training documents to LPA Martinez by POC date 04/28/2026 by 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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/07/2026 01:26 PM - It Cannot Be Edited


Created By: Avelina Martinez On 04/21/2026 at 02:10 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: 04/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(28)
87555(b)(28) General Food Service Requirements: The following food service requirements shall apply: (All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.


This requirement is not met as evidenced by: LPA Martinez observed the following foods not be be sealed properly and did not have experiations dates: Strawbarries w/frost bite, marinated chicken, and salad dressing bottle.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. The Licensee did not ensure food was not protected against contamination, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2026
Plan of Correction
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Facility staff agrees to conduct food service requirements training for all staff by poc date 05/12/2026. Facility staff agrees to email training documentation to LPA Martinez by POC date 05/12/2026 by 5:00 PM.
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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/07/2026 01:26 PM - It Cannot Be Edited


Created By: Avelina Martinez On 04/21/2026 at 02:22 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: 04/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
87309(a)
87309 Storage Space and Access: Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. The Licensee did not ensure cleaning solutions were made inaccessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2026
Plan of Correction
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Facility staff agrees to email LPA Martinez training agenda by POC date 04/22/2025 by 5:00PM. Facility staff agrees to conduct Storage Space and Access training to all staff by 05/12/2026 by 5:00 PM. Facility staff agrees to email LPA Martinez training materials by 05/12/2026 by 5:00 PM
Type A
Section Cited
CCR
87203
87203 Fire Safety:87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Two fire extinguishers did not have service tags and were not inspected, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2026
Plan of Correction
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During the annual inspection facility staff took fire extinguishers to get inspected, serviced, and tagged.
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: 04/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 05/07/2026 01:26 PM - It Cannot Be Edited


Created By: Avelina Martinez On 04/21/2026 at 02:36 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: 04/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
1569.695 (c) Emergency Plans A facility shall conduct a drill at least quarterly for each shift.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Facility was not able to provide fire drill log or fire drill dates, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2026
Plan of Correction
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3
4
Facility staff agrees to email a fire drill schedule plan and conduct a drill by 04/22/2026. Facility staff agrees to email LPA Martinez fire drill documentation by 04/22/2026 by 5:00 PM.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 04/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 05/07/2026 01:26 PM - It Cannot Be Edited


Created By: Avelina Martinez On 04/21/2026 at 02:43 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: 04/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
87463(a) Reappraisals: 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above 3 out of 3 residents did not have a yearly reappraisal, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2026
Plan of Correction
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Facility staff agrees to complete reappraisals for all residents in care by POC date 05/12/2026. Facility staff agrees to email reappraisals to LPA Martinez by poc date 05/12/26 by 5:00 PM
Type B
Section Cited
CCR
87412(a)(11)
87412(a)(11): Personnel Records: The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in 2 out of 3 staff did not have a health screening form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2026
Plan of Correction
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Facility staff agrees to obtain health screening for 1 staff member by 05/12/2026. Facility staff agrees to email health screening documentation to LPA Martinez by 05/12/2026 by 5:00 PM. Facility staff agrees to conduct a health screening file audit for all staff by 05/12/2026. Facility staff agrees to email audit documentation to LPA Martinez on 05/12/26 by 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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2026


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 05/07/2026 01:26 PM - It Cannot Be Edited


Created By: Avelina Martinez On 04/21/2026 at 03:06 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: WATERVIEW RESIDENCE
FACILITY NUMBER: 342701364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695
1569.695 ( a) Emergency Plans: (a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan…

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Facility staff was not able to provide an emergency plan or LICE 610e during the facility inspection, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2026
Plan of Correction
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2
3
4
Facility staff agrees to email LIC 610e and emergency plan to LPA Martinez by 04/22/2026 by 5:00 PM.
Type A
Section Cited
CCR
87470(d)(4)
87470(d)(4) Infection Control Requirements When an emergency, as defined in Government Code section 8558, or federal emergency for a contagious disease is proclaimed or declared, the licensee shall develop an Emergency Infection Control Plan that includes infection control measures that are not already addressed in the Infection Control Plan as specified in subsection (c), to prevent, contain, and mitigate the associated contagious disease. The Emergency Infection Control Plan shall be made available to residents, facility staff and, if applicable, each residents' representative.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Facility staff was not able to provide infection control plan during annual inspection, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2026
Plan of Correction
1
2
3
4
Facility staff agrees to email LPA Martinez Infection control plan by 04/22/2026
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: 04/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2026


LIC809 (FAS) - (06/04)
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