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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004525
Report Date: 03/28/2025
Date Signed: 04/04/2025 08:04:51 AM

Document Has Been Signed on 04/04/2025 08:04 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:EMBASSY FOUNTAIN INC. #2FACILITY NUMBER:
347004525
ADMINISTRATOR/
DIRECTOR:		NITTA, LEILANI M.FACILITY TYPE:
735
ADDRESS:10021 MOSAIC WAYTELEPHONE:
(916) 647-4267
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 6DATE:
03/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Leilani Nitta, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 03/28/25, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct an annual inspection of the facility. LPA Campbell met with Leilani Nitta, Administrator and explained the purpose of the visit.

The facility is a single story building with 5 bedrooms and 2 and a half bathrooms. It is licensed to serve 6 ambulatory developmentally disabled adults. The facility receives referrals from Alta Regional when they can accept new clients. Three of the bedrooms and 1 of the bathrooms are reserved for clients and 2 of the bathrooms are reserved for staff. Client bedrooms are for double occupancy. The administrator for the facility is Leilani Nitta, (#7002478735), who was present for today's inspection.

Upon entry, LPA Campbell observed no residents in the common areas of the facility. Staff reported that all residents but one were in day program. The common areas were free of debris and obstructions. LPA Campbell observed the 3 bedrooms were furnished as required with beds, chairs, night table and a closet was present in each room. Detergents are locked in a cabinet in the laundry room next to the garage. A freezer is in the garage with more than 7 days of perishables.

In the kitchen, knives are locked in a drawer next to the sink. A pantry with more than 7 days worth of non-perishables were observed. More cleaning products were observed in the kitchen and locked in a lower cabinet. Medications were also observed to be locked in a lower cabinet in the kitchen. The fire extinguisher was observed in the kitchen to be fully charged and last inspected on 07/11/2024. A sufficient amount of linens for the facility were observed. Smoke alarms and carbon monoxide alarms were tested and found to be functioning.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2025
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: EMBASSY FOUNTAIN INC. #2
FACILITY NUMBER: 347004525
VISIT DATE: 03/28/2025
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LPA Campbell toured the outside of the facility and observed no standing bodies of water. The backyard was observed to be well maintained. The path to the fire exit was clear with no obstructions. Screens were intact. Of the 6 clients living in the facility, 4 of their files were reviewed and found to be complete. There are 8 staff working in the facility and all staff on the facility roster were found to be finger print cleared on Guardian.

Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 6, no deficiencies are being cited. An exit interview was conducted with Leilani Nitta and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC809 (FAS) - (06/04)
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