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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
347004958
Report Date:
12/11/2024
Date Signed:
12/11/2024 02:25:53 PM
Document Has Been Signed on
12/11/2024 02:25 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 HOME
FACILITY NUMBER:
347004958
ADMINISTRATOR/
DIRECTOR:
SIEBENTHAL, ERMELINDA
FACILITY TYPE:
740
ADDRESS:
7948 HUNTS RUN WAY
TELEPHONE:
(916) 689-3595
CITY:
SACRAMENTO
STATE:
CA
ZIP CODE:
95828
CAPACITY:
6
CENSUS:
5
DATE:
12/11/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:
Ermelinda Siebenthal
TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 12/11/24 Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced POC inspection at Siebenthal Care Home to ensure previously cited deficiencies have been corrected.
LPAs met with the licensee to review plans of correction.
LPA observed staff are present at the facility and are in process of competing Medications training. Licensee was able to provide LPA with documentation of scheduled training with a RN and is scheduled to be completed on 12/17/24. Licensee has sent LPA first week of Medication administration records for all residents and will continue to provide to LPA weekly to ensure completeness of medication administration documentation and will continue to send weekly until February 10th 2025.
POC letters generated and provided to the Licensee.
Exit interview conducted and a copy of this report were left at the facility.
SUPERVISORS NAME
:
Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME
:
Kevin Gould
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/11/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/11/2024
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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