<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920257
Report Date: 05/06/2026
Date Signed: 05/06/2026 01:35:21 PM

Document Has Been Signed on 05/06/2026 01:35 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SIERRA HEALTH AND WELLNESS-ORANGEVALEFACILITY NUMBER:
345920257
ADMINISTRATOR/
DIRECTOR:		PHAM, LORNAFACILITY TYPE:
772
ADDRESS:5820 CHESTNUT AVETELEPHONE:
(530) 712-7482
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 16CENSUS: 15DATE:
05/06/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Staff, RN, Erica Self TIME VISIT/
INSPECTION COMPLETED:
01:50 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
Licensing Program Analyst ( LPA ) Talwinder Bains conducted a case management visit to this facility on 5/6/26.LPA met with Staff, RN, Erica Self and explained the purpose of today's visit.

The purpose of today's visit is to follow up the visit conducted at this facility by the Department of Healthcare Services (DHCS) on 3/24/26. Based on 3/24/26 facility visit, Department of Health Care Services (DHCS) issued facility’s evaluation report which indicated deficiencies issued to facility as a copy facility visit was received by Community Care Licensing Division (CCLD). The visit today is to address the issues found DHCS facility visit from 3/24/26 that apply to Title 22 Regulations.
Based on the DHCS report, the facility violated the following Title 22 violations:

-The admission agreement for three (3) residents (R1, R2, R3) were present but no documentation was available if residents receive a copy of admission agreement as required. **This is a repeat citation within 12 months.

-Record review indicated that for residents, R1 and R3 that the written assessments were not done as required upon admission.

- Record review reflected that the facility was unable to provide documented evidence that the staff preparing the treatment/rehabilitation plans had received training in these areas.

- Record review indicated that the facility was unable to provide documentation evidence that the treatment plan was completed for resident, R2 within 72 hours of admission as required.

Based on the above, deficiencies are cited pursuant to California Code of Regulations, Title 22 and documented on the attached LIC809D.

Exit interview conducted and copy of report, LIC809G and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Laura Munoz
NAME OF LICENSING PROGRAM ANALYST: Talwinder Bains
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2026
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 4
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)
Page: 2 of 4
Document Has Been Signed on 05/06/2026 01:35 PM - It Cannot Be Edited


Created By: Talwinder Bains On 05/06/2026 at 10:24 AM
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: SIERRA HEALTH AND WELLNESS-ORANGEVALE
FACILITY NUMBER: 345920257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2026
Section Cited
CCR
81068

1
2
3
4
5
6
7
81068- ADMISSION AGREEMENTS
(d) Such agreements shall be dated and signed, acknowledging the contents of the document...(f) The licensee shall retain in the client's file the original of the initial admission agreement and all subsequent modifications. (1) The licensee shall provide a copy ...this requirement is not met as evidenced by;
1
2
3
4
5
6
7
Licensee/Administrator shall send a statement of understanding of this regulation and will ensure that all components are completed for all residents as indicated with this regulation. All POC documents are due by 5/20/26.
8
9
10
11
12
13
14
Record review indicated that the admission agreement for three (3) residents (R1, R2, R3) were present but no documentation was available if residents receive a copy of admission agreement as required, which poses a potential risk to health and safety of residents in care.
8
9
10
11
12
13
14
Civil penalty of $250.00 was issued as this is a repeat violation within 12 months.
Type B
05/20/2026
Section Cited
CCR81068.2

1
2
3
4
5
6
7
81068.2- NEEDS AND SERVICES PLAN -(b) For each client admitted, the licensee shall ensure that a written Needs and Services Plan is started prior to admission, and completed prior to or within 72 hours of admission, that must include… this requirement is not met as evidenced by;
1
2
3
4
5
6
7
Licensee/Administrator shall send a statement of understanding of this regulation and submit a plan to ensure treatment plans are completed within the required timeframes.. All POC documents are due by 5/20/26.
8
9
10
11
12
13
14
Record review indicated that the facility was unable to provide documentation evidence that the treatment plan was completed for residents, R2 within 72 hours of admission as required, which poses a potential risk to health and safety of residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Talwinder Bains
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/06/2026 01:35 PM - It Cannot Be Edited


Created By: Talwinder Bains On 05/06/2026 at 10:31 AM
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: SIERRA HEALTH AND WELLNESS-ORANGEVALE
FACILITY NUMBER: 345920257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2026
Section Cited
CCR
81066

1
2
3
4
5
6
7
81066 PERSONNEL RECORDS
Staff training as required by Section 81065(r) shall be documented. Documentation shall include the subject of the training, who conducted the training, and the date(s) of the training. This requirement is not met as evidenced by;
1
2
3
4
5
6
7
Licensee/Administrator shall submit all completed training documentation to the Department as well as a plan on how the facility will ensure staff training will be conducted timely in the future. All POC documents are due by 5/20/26.
8
9
10
11
12
13
14
Record reviews reflected that the facility was unable to provide documented evidence that the staff preparing the treatment/rehabilitation plans had received training in these areas, which poses a potential risk to health and safety of residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Laura Munoz
NAME OF LICENSING PROGRAM MANAGER:
Talwinder Bains
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2026


LIC809 (FAS) - (06/04)
Page: 4 of 4