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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002859
Report Date: 02/23/2024
Date Signed: 02/23/2024 02:48:43 PM


Document Has Been Signed on 02/23/2024 02:48 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:MOAIFACILITY NUMBER:
345002859
ADMINISTRATOR:FOWLER, CRAIG M.FACILITY TYPE:
740
ADDRESS:2633 CARDINAL COURTTELEPHONE:
(916) 844-5250
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:3CENSUS: 1DATE:
02/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator and CaregiverTIME COMPLETED:
02:40 PM
NARRATIVE
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On 2/23/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management visit regarding a death report the department received on 2/20/2024. LPA met with Administrator, Craig Fowler, and explained the purpose of the visit.

Note: During time of LPA's visit, it was joined by Sacramento Metro Fire for fire clearance inspection. Facility was approved for change of ambulatory status to capacity of three- 2 ambulatory and 1 non-ambulatory. LPA will have license updated and mailed to facility once effective on system.

LPA and Administrator discussed that on 2/17/2024, R1 passed away in her sleep. Administrator reported R1 was on hospice services. Based on file review, LPA observed that R1 has a LIC 602 PHYSICIAN'S REPORT FOR RCFE on file that states R1 had non-ambulatory status. Additionally, LPA conducted a file review for R2 and observed R2's LIC 602 on file that states R2 has non-ambulatory status. Facility was originally licensed for three (3) ambulatory. End of visit, facility was cleared for fire clearance of one non-ambulatory. R2 has been relocated to a non-ambulatory approved room.

During today's visit, deficiencies was cited.

Exit interview and a copy of report and appeal rights provided to Administrator via email.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
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 2


Document Has Been Signed on 02/23/2024 02:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MOAI
FACILITY NUMBER: 345002859

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2024
Section Cited
CCR
87204(a)

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87204 Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license... This requirement is not met as evidenced by:
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Licensee has moved R2 to an approved non-ambulatory room.
Licensee will submit a statement of compliance to operate based on licensure.
POC due 2/24/2024.
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Based on file review, Licensee did not comply with the section cited above as R1 and R2 was accepted to the facility when facility was not licensed for non-ambulatory residents, which posed an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
LIC809 (FAS) - (06/04)
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