342701508-6-26-2025-27-AS-AVIA-DJ22PY-20250626173507

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701508
Report Date: 06/26/2025
Date Signed: 06/26/2025 05:35:49 PM

Document Has Been Signed on 06/26/2025 05:35 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:	SENIOR GUEST HOME		FACILITY NUMBER:	342701508
ADMINISTRATOR/ DIRECTOR:	DAY, EDYLYNE JOHANNA		FACILITY TYPE:	740
ADDRESS:	8890 HARLOW CT		TELEPHONE:	(702) 629-0201
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY: 6		CENSUS: 3	DATE:	06/26/2025
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Buluo Matamadua		TIME VISIT/ INSPECTION COMPLETED:	05:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/26/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived at this facility to conduct their post-licensing inspection. LPA met with designated staff, Buluo Matamadua (S5), and explained the purpose of the visit. Present during this visit were 3 residents in care with Present during this visit were 3 residents in care with 2 staff on duty (S1 and S5) LPA evaluated the physical plant with S5 to ensure the health and safety of the residents in care. The facility is a one-story home located in a residential neighborhood. Areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA inspected 3 of 3 resident bedrooms. Room #1, based on facility sketch, is currently shared by 2 residents. However, LPA observed one night stand between the two beds. Also in room #1, one resident drawer is in need of repair/replacement as evidenced by wood chipped off. Inside this drawer, LPA observed hygiene and grooming supplies. Per review of LIC602A, resident(s) is/are present at this facility is/are at risks if allowed to have access to these personal grooming and hygiene items. Room #1 also has its own bathroom. LPA observed hygiene and grooming products accessible to resident(s) who is/are at risks if they have access to these products. In this bathroom, LPA observed the toilet to be missing a toilet seat. Also, in room #1, the sliding screen door has been detached. Per interview with S5, one resident removed it. In room #2, LPA observed the floor at the entrance has part of it chipped off. In the bathroom at the hallway, a grab bar in front of the toilet was loose. Advisory was provided for necessary repair. Inspection of the kitchen was conducted. LPA observed knives and scissors inside one of the kitchen drawers, accessible to residents in care. The facility maintains sufficient seven day non-perishable and two day perishable food supplies. LPA measured the hot water in one resident bathroom and was measured at 106 degrees Fahrenheit. Room temperature was maintained at 76 degrees Fahrenheit. Fire extinguisher was last serviced on 9/4/2024. Smoke and carbon monoxide detectors were observed. {1 of 2}

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

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

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: SENIOR GUEST HOME	FACILITY NUMBER: 342701508
	VISIT DATE: 06/26/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Outdoor area was inspected. Facility has one side gate exit. The gate does not self lock properly. Advisory was provided to S5 to make necessary repair. Fence were observed to be in good repair at this time.

Review of 4 resident files (R1, R2, R3, R4) include review of Admission Agreement, Physician Reports, Needs and Services Plan, and Ambulatory Status. Through record review and interview, a resident passed away recently and their death report was not yet submitted to the Department and it is past the reporting requirement of 7 days following the incident.

Resident medications were not reviewed during this visit.

Review of 7 staff files (S1 - S7) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Administrator Certificate is current. Per review of Guardian, it was discovered that S1 is not associated to this facility. S1 immediately left the facility and another staff (S7) who is associated to this facility came shortly after to relieve S1.

Facility conducts quarterly disaster drill.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during today's visit.

Exit interview was conducted and a copy of the report was provided upon exit.

{2 of 2}

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025

LIC809 (FAS) - (06/04)

Page: 2 of 9

Document Has Been Signed on 06/26/2025 05:35 PM - It Cannot Be Edited

Created By: Arvin Villanueva On 06/26/2025 at 04:50 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: SENIOR GUEST HOME	FACILITY NUMBER: 342701508
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) 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
1 2 3 4	Based on [(observation) (record review)], the licensee did not comply with the section cited above. Scissors and knives were observed to be accessible to residents in care inside one of the ktichen drawers; grooming and hygiene products were accessible to residents who are at risks if given direct access to these items; two wooden items with nails sticking out were found inside a resident drawer. These pose an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/27/2025
	Plan of Correction
1 2 3 4	Corrected on site: facility representative (S5) immediately removed these items and place them in locked areas. Per discussion, licensee will submit a waiver to the Department for locking hygiene and grooming products. Waiver will include how they ensure other residents have access to these products. Waiver to be submitted by 7/4/25 to the Department.

Type A

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
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Staff on duty (S1) was initially present during the visit and was observed to provide care and supervision to residents in care. It was discovered through record reviews and interviews that S1 was not associated to this facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/27/2025
	Plan of Correction
1 2 3 4	Corrected on site: S1 was asked to immediately remove themselves from this facility and a replacement staff arrived shortly after. Per discussion with facility representative (S5), licensee will submit a transfer request to associate S1 to this facility before S1 returning to work.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:

	Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025

LIC809 (FAS) - (06/04)

Page: 3 of 9

Document Has Been Signed on 06/26/2025 05:35 PM - It Cannot Be Edited

Created By: Arvin Villanueva On 06/26/2025 at 05:08 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: SENIOR GUEST HOME	FACILITY NUMBER: 342701508
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(a)(1)(A)

Reporting Requirements: (a)(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. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(interview) (record review)], the licensee did not comply with the section cited above. Licensee did not provide a written report of resident's death in a timely manner as required, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/27/2025
	Plan of Correction
1 2 3 4	Corrected on site: facility representative (S5) provided the death report to licensee during this visit. S5 stated she forgot to submit and ensure adherence to timely reporting requirement moving forward.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

	Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:

	Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025

LIC809 (FAS) - (06/04)

Page: 9 of 9