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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004958
Report Date: 10/23/2024
Date Signed: 10/23/2024 02:37:45 PM


Document Has Been Signed on 10/23/2024 02:37 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:SIEBENTHAL CARE HOMEFACILITY NUMBER:
347004958
ADMINISTRATOR:SIEBENTHAL, ERMELINDAFACILITY TYPE:
740
ADDRESS:7948 HUNTS RUN WAYTELEPHONE:
(916) 689-3595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
10/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Emerlinda SiebenthalTIME COMPLETED:
03:15 PM
NARRATIVE
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On 10/23/24 at 9:20am, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management inspection to address deficiencies observed regarding facility staff and resident records maintained by the facility. LPA met with the licensee and together discussed LPA's observations. LPA identified missing/incomplete records observed and provided licensee with ample time to locate items requested and identified as missing in resident and staff files.

LPA observed the following: There is currently not a certified administrator associated to the facility. The licensee (S1) has completed all required hours for recertification but has not yet submitted the documents to be recertified. LPA observed there is a pending initial administrator certificate for the other licensee (S2). Although the licensee claims they are renewing the administrator certificate, could not provide LPA with the most recent certificate and the documents submitted did not identify the certificate number for S2 and did not include an expiration date.

Additionally, LPA reviewed all staff files and observed the facility did not follow title 22 regulations in 2017 when they hired a 17 year old caregiver identified as S3. Upon additional file reviews for staff member LPA observed S2, S4, S5 and S6 did not have current health screening or TB test on file.

LPA also observed that S6 also does not have a criminal record clearance despite working at the facility since 4/28/24. S7 must obtain a criminal record clearance and be associated to the facility prior to being present in the facility or working with residents.

Report continued on LIC 9099-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024
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 4


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: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958
VISIT DATE: 10/23/2024
NARRATIVE
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LPA reviewed all five current resident files and one former resident file. LPA observed all residents placed at the facility have a diagnosis of dementia per their physician's report (LIC 602) LPA observed two of the current residents did not have a current 602 as they were over a year old.

Per the California Codes of Regulations, Title 22, the following deficiencies are cited during today's inspection. An immediate civil penalty has been issued as one of the staff members present does not have a criminal record clearance.

Exit interview conducted and a copy of this report and appeal rights were left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/23/2024 02:37 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: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2024
Section Cited
CCR
87355(e)(1)

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Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption. This requirement was not met as evidenced by statements from S1
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Licensee has agreed to ensure S6 has a criminal record clearance prior to working again in the facility and has agreed to provide a written plan of correction indicating the steps facility will take to ensure the violation does not reoccur.
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regarding S6's working at the facility since April 2024 without a criminal record clearance which poses an immediate health, safety or personal rights risk to residents in care.
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Type A
10/25/2024
Section Cited
CCR87405(a)

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Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient
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Licensee has agreed to submit documentation of all required training to the Administrator Certification Bureau by the POC due date ad submit an LIC 200 and all supporting documents to appoint staff member with a pending certification. once completed, LPA will request an expedited certification of the identified staff member.
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number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section... this requirement was not met as evidenced by: LPA observations there is no current certified administrator and the administrators whose certificate expired has yet to submit documents for renewal which poses an immediate health, safety or personal rights 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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/23/2024 02:37 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: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2024
Section Cited
CCR
87411(f)

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Personnel Requirements - General: All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal
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Licensee has agreed to ensure all identified staff without documentation of a health screening or TB test to be scheduled immediately and will submit a written report indicating the steps facility will take to ensure the violation does not reoccur.
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physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall test, performed bya be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents wich poses an immediate health, safety or personal rights risk to residents incare.
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Type B
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Section Cited
CCR87705(c)(5)

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Care of Persons with Dementia: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the
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Licensee has agreed to have all physician reports and needs and services plans updated for the identified residents by the POC due date.
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 resident’s dementia care needs. This requirement was not met as evidenced by LPA observations that two of the five resident's in placement did not have an annual 602 and needs and services plan updated annually pre regulations which poses a potential health, safety or personal rights 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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4