347001078-8-18-2025-27-AS-APAA-DKNQ5Y-20250818115243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347001078
Report Date: 08/18/2025
Date Signed: 08/18/2025 11:52:51 AM

Document Has Been Signed on 08/18/2025 11:52 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:	COURTYARD TERRACE		FACILITY NUMBER:	347001078
ADMINISTRATOR/ DIRECTOR:	MAGDA LUIS		FACILITY TYPE:	740
ADDRESS:	3408 ALTA ARDEN EXPRESSWAY		TELEPHONE:	(916) 486-1281
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY: 40		CENSUS: 40	DATE:	08/18/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Magda Luis		TIME VISIT/ INSPECTION COMPLETED:	12:15 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 08/18/2025, Licensing Program Analyst (LPA) Arielle Pascua and Department Representatives, Sarauanan Mani, Naga Chinduluru, Dana Schoppers, and Raj Mudiganga arrived unannounced to this facility to conduct an annual visit. LPA met with Facility Designated Administrator (FDA), Magda Luis and explained the purpose of the visit. The purpose of this visit was to conduct an annual visit. This facility is licensed to serve 40 residents who are deemed non-ambulatory and has a hospice waiver for 10. This facility also obtains Assisted Living Waiver Residents. LPA reviewed 4 resident files and 4 staff files. All staff and resident files were complete and up to date. A tour of the facility was conducted. The administrator has a current and active administrator certificate #7018207740 and expires on 1/21/2027. A tour of the facility was conducted. All rooms designated as activity areas and common areas for resident use were toured. Furniture and furnishings were observed to be present and sufficient to meet the needs of the residents at this time. Office rooms and other areas intended for resident use were toured. Kitchen area was toured. Facility freezer and refrigerator units were toured. LPA reviewed the food storage supply to make sure that there was always a 2-day perishable and 7-day nonperishable food quantities on site at all times. Knives were observed to be locked and made inaccessible to the residents at this time. It was observed in that the facility has cafe areas equipped with a microwave and addition refrigerator present to cool, heat, and warm up food of the residents if necessary. Storage area for chemicals and cleaning supplies were observed to be locked and made inaccessible to the residents at this time.

Lisa Rios	TELEPHONE: (916) 969-9685
Arielle Pascua	TELEPHONE: (916) 862-5907
	DATE: 08/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025

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: COURTYARD TERRACE	FACILITY NUMBER: 347001078
	VISIT DATE: 08/18/2025

NARRATIVE

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A tour of the facility resident bedrooms was conducted. Furniture and furnishings were observed to sufficient and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Medication room was reviewed. It was learned that narcotics and all other medications were housed in medication carts that were used to store and dispense medications to the residents at this time. This facility has an electronic Medication Administration Record system. A brief interview was conducted with facility staff responsible for handling, dispensing, and documentation of the medications at this time. First aid kit was observed to be present and contained all of the required components at this time. First aid kit was observed to be present and contained all of the required components at this time.

Exterior grounds of this facility was toured. Perimeter fence and gates were observed to be functional and in good repair at this time. Delayed egress and other safety measures were observed to be functional at this time.
Fire extinguishers, located and placed throughout the facility, were observed to have been annually inspected on 03/05/2025 by the local fire extinguisher company noted as Fire Code and in compliance at this time. All smoke and carbon monoxide detectors were present and working at this time.

The following forms and documents were requested to be updated and submitted into CCL:
-LIC 308
-LIC 400
-LIC 500
-LIC 610e
A technical violation was provided for 87303(a).

As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to Facility Designated Administrator.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: (916) 862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025

LIC809 (FAS) - (06/04)

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