347003426-1-22-2025-27-AS-PLEE-DD6SUX-20250122131153

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003426
Report Date: 01/22/2025
Date Signed: 01/22/2025 01:12:20 PM

Document Has Been Signed on 01/22/2025 01:12 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:	DEL VISTA RESIDENTIAL CARE		FACILITY NUMBER:	347003426
ADMINISTRATOR/ DIRECTOR:	SAEL, TATY L.T.		FACILITY TYPE:	740
ADDRESS:	78 DEL VISTA CIRCLE		TELEPHONE:	(916) 690-7243
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS:	DATE:	01/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:36 AM
MET WITH:	Taty Sael		TIME VISIT/ INSPECTION COMPLETED:	01:25 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 01/22/24, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA met with direct care staff Rosemerry Manariangkuba and Rosita Sagala and explained the purpose of the visit. Direct care staff called and informed administrator Taty Sael to informed that CCLD was present in the facility. Administrator arrived at the facility approximately 20 minutes later and assisted with today’s visit. Administrator certificate # is 7034190740 and will expire on 06/02/25. The current census is 6 with 2 facility staff. This facility is a single story building licensed to six (6) non-ambulatory residents and approved for 3 hospice residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, residents’ bedrooms, residents’ bathrooms, laundry room, garage, and outside courtyards of the facility to ensure compliance with Title 22 regulations. It was observed the facility was free of odor and clean. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed the facility had sufficient seven day non-perishable food supplies and two day perishable food supplies at this time. Hot water temperature was measured at 114.6 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 kitchen and was last serviced on 11/26/24. The last fire drill was conducted on 10/08/24. LPA observed the facility has a has a public telephone in the kitchen. Facility thermostat observed at 72 degrees Fahrenheit. LPA observed toxins located in the garage and kept locked; however, LPA did observe a Lysol disinfectant spray in the hallway which was made accessible to residents in care at this time. LPA observed sharp knives kept locked and inaccessible to residents. LPA checked medication storage and found medication to be locked away and inaccessible to residents. Continued LIC 809-C

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Pang Lee	TELEPHONE: (916) 508-9726
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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 6

Document Has Been Signed on 01/22/2025 01:12 PM - 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DEL VISTA RESIDENTIAL CARE	FACILITY NUMBER: 347003426
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

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. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above. LPA Lee observed a Lysol disinfectant spray made available to residents in care which poses an immediate health, safety or personal rights risk to persons in care
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	During today's visit, administrator locked up the Lysol disinfectant spray. Administrator and all staff will review the regulation cited and provide LPA Lee a statement of acknowledge me of reading and understanding the regulation cited. POC due to LPA Lee by end of day 01/31/25 at 5:00 PM.

Section Cited

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (2) The exact dosage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review and interview the licensee did not comply with the section cited above. It was learned that 2 of the residents MAR logs are incomplete. The MARs didn’t have the exact and correct dosage. This poses an immediate health and safety risks to residents in care.
	POC Due Date: 01/29/2025
	Plan of Correction
1 2 3 4	Administrator will conduct an incidental medical training to all facility staff. The training will include “The five rights of medication administration.” Administrator and all staff will review the regulation cited and provide LPA Lee a statement of acknowledge me of reading and understanding the regulation cited. Training material/information used, training sign in sheet and statement will be email to LPA Lee. POC due to LPA Lee by end of day 01/31/25 at 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.

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Pang Lee	TELEPHONE: (916) 508-9726
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

Page: 2 of 6

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: DEL VISTA RESIDENTIAL CARE	FACILITY NUMBER: 347003426
	VISIT DATE: 01/22/2025

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
26
27
28
29
30
31
32

LPA reviewed and 3 out of 6 residents medication administration record (MAR) along with residents medications and 2 out of 3 MAR was not complete. It was observed that 2 of the residents MARs did not have the correct physician's order and exact dosage. The first aid kit was checked, and it was complete. LPA requested resident and staff files for review. LPA Lee reviewed 5 out of 6 resident files and 1 out of 5 resident file was incomplete. Resident 1 (R1) did not have a complete LIC 625 Appraisal/Needs and Service. It was observed that the LIC 625 was blank with no signatures. LPA reviewed staff files and they were not complete. 1 out of 2 staff files were missing annual training's. LPA toured the courtyard and observed the emergency gate not in good repair. LPA 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.

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies 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, LIC 9102 Technical Violation and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 01/22/2025 01:12 PM - 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DEL VISTA RESIDENTIAL CARE	FACILITY NUMBER: 347003426
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above. LPA Lee observed the emergency gate in despair. The gate was hard to open which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/29/2025
	Plan of Correction
1 2 3 4	Administrator agrees to fix the emergency gate and ensure that it is easily open. Administrator will review the regulation cited and provide LPA Lee a statement of acknowledge of reading and understanding the regulation cited.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Pang Lee	TELEPHONE: (916) 508-9726
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 01/22/2025 01:12 PM - 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DEL VISTA RESIDENTIAL CARE	FACILITY NUMBER: 347003426
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87459 Functional Capabilities (a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. The licensee did not ensure R1 has a completed LIC 625 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/29/2025
	Plan of Correction
1 2 3 4	During today’s visit, the administrator completed the LIC 625 with R1 and address R1’s needs and services with transferring and shower needs. Administrator will ensure that all residents have a complete LIC 625. Administrator and all staff will review the regulation cited and provide LPA Lee a statement of acknowledge me of reading and understanding the regulation cited. POC due 01/29/25 end of day 5:00 PM.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Pang Lee	TELEPHONE: (916) 508-9726
	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC809 (FAS) - (06/04)

Page: 6 of 6