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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003936
Report Date: 03/07/2024
Date Signed: 03/07/2024 11:57:38 AM


Document Has Been Signed on 03/07/2024 11:57 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:TENDER HOME SENIOR CAREFACILITY NUMBER:
347003936
ADMINISTRATOR:MARINOVA, VALENTINAFACILITY TYPE:
740
ADDRESS:3499 PONZI COURTTELEPHONE:
(916) 851-1888
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:6CENSUS: 5DATE:
03/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Valentina MarinovaTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on a subsequent complaint investigation visit on 3/7/24 at 8:45am. LPA met with Licensee Valentina Marinova and stated the purpose of the visit.

During the visit LPA was unable to review Resident #1 (R1) facility records which were not made available for review during the visit.

In addition, LPA observed the Licensee did not submit Incident reports regarding falls and hospitalization's of R1. These deficiencies were confirmed by the Licensee during this visit.

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 Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
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 2


Document Has Been Signed on 03/07/2024 11:57 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: TENDER HOME SENIOR CARE
FACILITY NUMBER: 347003936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2024
Section Cited
CCR
87506(a)

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Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
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Licensee shall submit by fax a statement that all records will be made readily available for review upon request.
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This requirement is not met as evidenced by: Based on LPA observation R1's records were not made available for review during this visit. This violation poses an immediate health, and safety risk to residents in care.
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Type A
03/08/2024
Section Cited
CCR87211(a)(1)

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Reporting Requirements
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Licensee shall submit by fax a statement that in all instances that a report is warranted they are to be submitted by fax to CCL.
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This requirement is not met as evidenced by: Based on Licensee admittance that the reporting requirements has not been met. This violation poses 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: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2