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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000923
Report Date: 01/06/2025
Date Signed: 01/21/2025 01:51:52 PM

Document Has Been Signed on 01/21/2025 01:51 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:CARMEN'S CARE HOMEFACILITY NUMBER:
347000923
ADMINISTRATOR/
DIRECTOR:		NAVARRO, CARMENFACILITY TYPE:
740
ADDRESS:5392 MEADOW PARK WAYTELEPHONE:
(916) 427-1828
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
01/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Cynthia NavarroTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
NARRATIVE
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On 01/06/25 at 8:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care giver Cynthia Navarro who then called the facility designated administrator (FDA) Carmen Navarro to informed that CCLD was present in the facility. FDA arrived approximately 30 minutes later. Administrator assisted with today’s visit. The current census is 5 with 2 facility staff.

This facility is a single story building licensed to serve six (6) non-ambulatory residents. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 112.3 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in common area and was last serviced on 01/03/25. The last fire drill was conducted on 12/20/24. LPA Lee observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. Facility thermostat was observed at 72 degrees Fahrenheit. LPA Lee observed toxins located in resident bathroom cabinet and in the laundry room and they both were not kept locked and made accessible to residents at this time. LPA Lee observed sharp knives kept locked in the kitchen cabinet and inaccessible to residents.
Continued LIC 809-C
Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
Pang LeeTELEPHONE: (916) 508-9726
DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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 5
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: CARMEN'S CARE HOME
FACILITY NUMBER: 347000923
VISIT DATE: 01/06/2025
NARRATIVE
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 LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed and compared 3 out of 5 medication administration record (MAR) and it was complete. The first aid kit was checked and contained all the required components.

LPA Lee requested resident and staff files for review. LPA Lee reviewed 5 out of 5 resident files and they were not complete. 2 out of 5 resident files did not have a current Individual Progress Plan (IPP) and the most current IPP in the file are dated for 2022. LPA Lee reviewed 3 staff files and it was not complete. Staff 1 (S1) is missing 20 hours of annual training for 2024 and S2 did not have any documentation of dementia training prior to caring for dementia residents in the facility. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents will be email to LPA by 01/10/25 end of day 5:00 PM:
(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate
(4) LIC 610 Current Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) LIC 500 Current Personnel Report
(7) LIC 309 Administrator Organization

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/21/2025 01:51 PM - It Cannot Be Edited


Created By: Pang Lee On 01/06/2025 at 11:43 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: CARMEN'S CARE HOME
FACILITY NUMBER: 347000923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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
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Based on observation, the licensee did not comply with the section cited above. LPA Lee observed toxins located in the resident bathroom cabinet and laundry room unlocked and made accessible to residents in care. This poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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During today's visit administrator fixed the lock cabinet in the resident bathroom and removed the toxins in the laundry room and locked the toxins. Administrator will review the regulation cited and email LPA Lee a statement of acknowledgement of understanding the regulation cited by POC date 01/10/25 end of day 5:00 PM.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Czarrina A Camilon-Lee
TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME:Pang Lee
TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/21/2025 01:51 PM - It Cannot Be Edited


Created By: Pang Lee On 01/06/2025 at 11:44 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: CARMEN'S CARE HOME
FACILITY NUMBER: 347000923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626
§1569.626 Training requirements for direct care staff
(a) All residential care facilities for the elderly shall meet the following training requirements…
(1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review S2 does not have any dementia training. This poses an immediate health and safety risk to residents in care.
POC Due Date: 01/17/2025
Plan of Correction
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Administrator agrees to sign S2 for dementia training. Administrator will email LPA Lee documentation/certificate of training completed to LPA Lee. Administrator will review the regulation cited and email LPA Lee a statement of acknowledgement of understanding the regulation cited by POC date 01/17/25 end of day 5:00 PM.
Type B
Section Cited
HSC
1569.625(b)(2)
§1569.625 Staff training; legislative findings; contents
(b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training.
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually,

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review S1 does not have 20 hours of annual training. This poses a potential health and safety risk to residents in care.
POC Due Date: 01/17/2025
Plan of Correction
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Administrator agrees to sign S1 for annual training. Administrator will email LPA Lee documentation/certificate of training completed to LPA Lee. Administrator will review the regulation cited and email LPA Lee a statement of acknowledgement of understanding the regulation cited by POC date 01/17/25 end of day 5:00 PM.
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:Czarrina A Camilon-Lee
TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME:Pang Lee
TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2025


LIC809 (FAS) - (06/04)
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