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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003426
Report Date: 09/01/2026
Date Signed: 09/01/2026 09:36:08 AM

Document Has Been Signed on 09/01/2026 09:36 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:DEL VISTA RESIDENTIAL CAREFACILITY NUMBER:
347003426
ADMINISTRATOR/
DIRECTOR:		SAEL, TATY L.T.FACILITY TYPE:
740
ADDRESS:78 DEL VISTA CIRCLETELEPHONE:
(916) 690-7243
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 6DATE:
09/01/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:14 AM
MET WITH:Rosamary Manaringkuba.TIME VISIT/
INSPECTION COMPLETED:
09:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced on 09/01/2026 to conduct a case management visit. LPA Lee met with care staff Rosamary Manaringkuba and explained the purpose of the visit. The facility census was six residents. A brief interview was conducted with Administrator Taty Sael via telephone.

The purpose of today's visit was to follow up on a LIC 624 Incident Report received by the Department on 07/14/2026. According to the incident report, on 07/13/2026 at approximately 9:45 PM, care staff discovered that Resident 1 (R1) could not be located within the facility or the surrounding area. Staff reported that R1 was last seen at approximately 9:15 PM in their bedroom. After conducting a search of the facility and the immediate vicinity, staff were unable to locate R1. At approximately 10:20 PM, Administrator Taty Sael contacted law enforcement and reported R1 as a missing person. At approximately 11:00 PM, law enforcement located R1 at a nearby train station and returned the resident to the facility; however, the resident wanted to go to the hospital due to an injury. A review of R1's LIC 602, Physician's Report, dated 07/06/2026, documented that R1 is unable to leave the facility unsupervised and requires supervision or hands-on assistance. During the phone call with Administrator Sael, who stated that facility staff were already suspicious of R1’s behavior as R1 had their clothes hanging on their wheelchair. Based on the information obtained during today's case management visit, the facility did not provide adequate care and supervision to ensure R1's safety, resulting in R1 leaving the facility unsupervised and being reported as a missing person. This posed an immediate risk to the resident's health and safety. Therefore, a deficiency is being cited under California Code of Regulations, Title 22, Division 6, for lack of care and supervision. An immediate civil penalty of $500 was assessed on 09/01/2026.

An exit interview was conducted with care staff Manaringkuba. A copy of this LIC 809, LIC 809-D, LIC 421D, and the Licensee/Appeal Rights was provided to the facility at the conclusion of the visit.

Arielle Pascua
Pang Lee
DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2026
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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Document Has Been Signed on 09/01/2026 09:36 AM - It Cannot Be Edited


Created By: Pang Lee On 09/01/2026 at 09:19 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: DEL VISTA RESIDENTIAL CARE
FACILITY NUMBER: 347003426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2026
Section Cited
CCR
87464(f)(1)

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87464(f)(1) Basic Services
(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement was not met as evidenced by:
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The Licensee/Administrator will ensure the facility is in compliance with Title 22 regulation 87464 at all times. Per the Administrator, after the incident an alarm is also placed in the staff room to alarm
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This requirement was not met as evidenced by:
Based on records review and interview, the facility did not ensure that a resident in care was kept under continuous supervision which resulted in elopement. On 7/13/2026 resident (R1) eloped from the facility, without facility staff awareness, and sustain injury which poses in immediate Health and Safety risk to residents in care.
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staff when the front door is opened. The licensee will conduct training with all facility staff working in the facility on care and supervision, and resident elopement. Licensee will send LPA proof of training by 09/15/2026.

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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.
Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2026


LIC809 (FAS) - (06/04)
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