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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001970
Report Date: 07/07/2022
Date Signed: 07/07/2022 10:03:09 AM


Document Has Been Signed on 07/07/2022 10:03 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:WATERLEAF AT LAND PARK, THEFACILITY NUMBER:
347001970
ADMINISTRATOR:CIMINO, PAULFACILITY TYPE:
740
ADDRESS:966 43RD AVENUETELEPHONE:
(916) 394-9400
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:78CENSUS: 51DATE:
07/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Coreen TigleyTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on a subsequent visit on 7/7/22 at 8:15am. LPA met with Coreen Tigley and stated the purpose of the visit. This visit is to conduct a Case Management visit regarding an incident report received by Community Care Licensing (CCL) on 6/14/22 indicating that resident #1 (R1) was found by the Fire Department walking down the street from the facility.

LPA interviewed the Administrator regarding the incident during todays visit. LPA received and reviewed the most current LIC602 Physician report for R1. The Physician report indicated that R1 has a diagnosis of Dementia and is unable to leave the facility unassisted.

The investigation revealed that the facility did not supervise R1 which allowed R1 to elope from the facility. The preponderance of the evidence standard has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
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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Document Has Been Signed on 07/07/2022 10:03 AM - 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: WATERLEAF AT LAND PARK, THE
FACILITY NUMBER: 347001970

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2022
Section Cited

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Care of Persons with Dementia

Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents if they wander away from the facility.
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This requirement is not met as evidenced by: A review of submitted SIR and confirmation of Administrator R1 AWOL'd on 6/14/22.
Based on interview the Administrator did confirm the AWOL on 6/14/22. This possess 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
LIC809 (FAS) - (06/04)
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