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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004958
Report Date: 03/08/2023
Date Signed: 03/08/2023 10:28:42 AM


Document Has Been Signed on 03/08/2023 10:28 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: 6DATE:
03/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Emerlinda SiebenthalTIME COMPLETED:
11:00 AM
NARRATIVE
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On 03/08/2023, Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA Martinez met with Emerlinda Siebenthal and explained the purpose of the visit.

The purpose of the visit today, is in response to learned deficiencies from complaint investigation 27-AS-2022122114395. It was learned the Licensee of this facility did not implement Title 22 eviction regulations, and resident 1 (R1) was improperly evicted. Furthermore, R1's responsible party (RP) requested a prorated refund, which was denied by the Licensee. It was learned R1's belongings were removed from the facility around 3:00 PM on December 29, 2022. A refund shall be given if necessary.

Moreover, R1's cell phone was confiscated by the facility due to viewing inappropriate websites. However, R1' is not conserved, therefore, R1 is responsible for their belongings and decision making. It reported the cell was returned to R1. However, the cell phone has been misplaced and missing. It is uncertain who misplaced R1's cell phone. Furthermore, a facility note dated October 21, 2022, reported the facility would take punitive actions if R1 continued having behaviors. As a result, the facility showed they were planning to implement punitive actions R1. A technical violation was given to the facility.

The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of this 809 report and appeal rights were given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
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 03/08/2023 10:28 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2023
Section Cited

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1569.652(c)A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals....within 15 days after the personal property is removed. This requirement was not met as evidence by:
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Licensee agrees to: review Refund regulations by POC date 03/20/2023. LPA a written statement stating eviction regulations have been reviewed by POC date 03/20/2023
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Based on file review and interviews: the Licensee refused to provide a refund to R1 due to his behavior. This posed a potential health and safety risk to R1.
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Type B
03/21/2023
Section Cited

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87468.1(a)(3) Personal Rights of Residents in all Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: or wear their own clothes; to keep and use their own personal possessions...This requirement was not met as evidence by:
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Licensee agrees to: review Personal rights by POC date 03/20/2023 . Licensee agrees to email LPA a written statement stating eviction regulations have been reviewed by POC date 03/20/2023.
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Based on record review and interviews, the Licensee confiscated R1's cell phone, which the cell phone is now missing This posed a potential health and safety risk to R1
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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) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2