347000407-9-22-2026-27-AS-SLOZ-DY6Q4T-20260922115053

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347000407
Report Date: 09/22/2026
Date Signed: 09/22/2026 11:51:05 AM

Document Has Been Signed on 09/22/2026 11:51 AM - 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:	CYON SAMALA FAMILY CARE HOME #2		FACILITY NUMBER:	347000407
ADMINISTRATOR/ DIRECTOR:	SAMALA, ASUNCION CJ.		FACILITY TYPE:	740
ADDRESS:	1547 BELL STREET		TELEPHONE:	(916) 929-9699
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY: 6		CENSUS: 5	DATE:	09/22/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Administrator Hiyasmin Samala		TIME VISIT/ INSPECTION COMPLETED:	12:00 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 September 22, 2026, at 9:00 AM, Licensing Program Analyst (LPA) Sulma Lopez arrived unannounced at the facility to conduct an annual required inspection. LPA Lopez met with Administrator 1 (A1) Hiyasmin Samala and explained the purpose of today's visit. The Administrator holds current certificate #7033096735 and expires on May 28, 2027. The facility is licensed for six (6) clients ages 60 and above. There are currently five (5) clients residing at the facility. At 9:20 AM, LPA conducted record reviews of five (5) staff and five (6) client files. The staff files were observed to contain updated training records. Client files contained needs and services plans, health screening reports, and TB test records. At 10:30AM, LPA reviewed two (2) Clients' medication administration records. Medications were stored in a locked cabinet. The facility uses a MAR sheet to record all dispensed medication. The facility conducts monthly fire drills and the most recent one took place on August 2, 2026. At 10:45AM, LPA Lopez toured the physical plant including but not limited to the kitchen, dining room, resident bedrooms, facility bathrooms, and outside courtyards of the facility to ensure compliance with Title 22 regulations. The facility kitchen was observed to contain at least 7 days worth of non-perishable food supply and at least 2 days of perishable food supply. The facility stores knives in a locked container. Cleaning supplies and toxins were stored in a locked cabinet under the sink. Continued on LIC 809-C.

Arielle Pascua
Sulma Lopez
	DATE: 09/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026

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: CYON SAMALA FAMILY CARE HOME #2	FACILITY NUMBER: 347000407
	VISIT DATE: 09/22/2026

NARRATIVE

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The dining room was clean and free of hazards. There was enough seating available for the current census. LPA observed residents listening to music and coloring in the common areas. LPA observed a public telephone available for resident use in the living room.

LPA toured the facility restrooms which were clean and sanitary. The shower contained non-slip mats and grab bars for resident safety.

LPA toured 3 out of 3 client bedrooms. The bedrooms contained clean bedding and the furniture was in good repair. The client bedrooms contained smoke detectors and exit doors. LPA observed a resident bed who is no longer at the facility. It was learned that the resident resided at the facility for 1 day and was hospitalized shortly after. LPA reviewed fax records and email records but did observe any incidents reported for the facility. LPA reviewed Reporting Requirements with A1.

The facility temperature was 73 degrees. The facility's hot water temperature was 106 degrees. The fire extinguishers were serviced annually on September 14, 2026.

The facility courtyards were observed to contain a shaded seating area for resident use. The walkways were clear of obstructions. The LPA observed piles of cardboard which Staff 1 (S1) stated will be picked up by waste management tomorrow.

LPA Lopez requested the following documents be sent to the Regional Office within 15 days: LIC 500 Personnel Report, LIC 308 Designation of Facility Representative, LIC 610E Emergency and Disaster Plan, and copy of surety bond.

As a result of this annual inspection visit, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Sulma Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2026

LIC809 (FAS) - (06/04)

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