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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701544
Report Date: 07/09/2026
Date Signed: 07/09/2026 04:36:29 PM

Document Has Been Signed on 07/09/2026 04:36 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:CARLITO'S CARE HOME LLCFACILITY NUMBER:
342701544
ADMINISTRATOR/
DIRECTOR:
FLORES, ELVISFACILITY TYPE:
740
ADDRESS:8554 WILLOW GROVE WAYTELEPHONE:
(916) 667-8424
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 4CENSUS: 4DATE:
07/09/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:15 PM
MET WITH:Elvis Flores and Joanna FloresTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On July 9, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), conducted an unannounced case management visit at this facility. LPA met with administrator, Elvis Flores (AD), and explained the purpose of the visit. The purpose of the visit is to address facility action report (FAR) prepared by Alta Regional Center dated March 25, 2026. Present during this visit were four clients in care with two staff on duty. The licensee, Joanna Flores, arrived shortly after.

Per FAR, ACRC representative conducted a review of the client’s medication records and corresponding medication supply. Documentation signed by the client’s physician indicated that Medication-1 (M1) 250 mg, previously ordered for administration every Monday, Wednesday, and Friday, was discontinued effective 02/12/2026.

A review of the Medication Administration Record (MAR) confirmed that facility staff accurately reflected the discontinuation and did not administer the medication during the March 2026 medication cycle. Despite appropriate MAR documentation, inspection of the client’s March bubble pack revealed that M1 tablets remained present.

According to the report, AD reported that a request had been made to the pharmacy to remove the discontinued medication from the bubble pack. The pharmacy declined, stating that bubble packs could not be altered after packaging. As a result, staff have been manually removing M1 tablets from the bubble pack, placing them into a separate Ziploc bag, and storing them apart from the client’s currently active medications.

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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2026
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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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: CARLITO'S CARE HOME LLC
FACILITY NUMBER: 342701544
VISIT DATE: 07/09/2026
NARRATIVE
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Upon inspection of the Ziploc bag, the ACRC representative observed four (4) tablets present. Based on the March bubble pack cycle beginning Monday, March 2, a total of ten (10) tablets should have been available. Six (6) tablets were unaccounted for, and there were no corresponding MAR entries, destruction logs, or staff signatures documenting their removal, disposition, or handling.

Based on the information above, this facility is hereby cited pursuant CCR Title 22, Division 6, Chapter 8. An exit interview was held with AD and Licensee. A copy of this report and appeal rights were provided.

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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/09/2026 04:36 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 07/09/2026 at 03:28 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: CARLITO'S CARE HOME LLC

FACILITY NUMBER: 342701544

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2026
Section Cited
CCR
87465(h)(6)

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The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained...
This requirement is not met as evideced by:
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Corrected prior to this visit. POC was submitted to Alta California Regional Center.
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Based on observation, record reviews and interviews, the licensee did not comply with the regulation cited. There were missing medication tablets with no supporting documents. This poses an immediate health, safety, and/or personal rights risk to persons in care.
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2026


LIC809 (FAS) - (06/04)
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