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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004958
Report Date: 07/27/2023
Date Signed: 07/27/2023 04:15:57 PM


Document Has Been Signed on 07/27/2023 04:15 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 AC/SC, 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: 4DATE:
07/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Ermelinda SiebenthalTIME COMPLETED:
04:30 PM
NARRATIVE
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On 07/27/2023 at 2:10 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to conduct a case management visit. LPA Lee met with care staff, Carol Carvantes. Care staff called administrator, Emelinda Siebenthal. Administrator arrived approximately 10 minutes later. LPA Lee explained the purpose of the visit. The purpose of today’s visit is to follow up on a 30 days eviction noticed.

LPA Lee requested the following documents for resident (R1). Licensee will emailed the following documents to LPA Lee by 07/31/2023 by end of day 5:00 PM.

1) LIC 602- Current Physician report

2) New and current admission agreement

3) Revised draft of the eviction letter


During today's visit, It was learned that (2) out of (4) facility staff are not associated to the this facility prior to working at this facility. It was also learned that (1) out of (4) facility staff was not fingerprint cleared prior to working at the facility. PA Lee advised administrator that any staff that is not fingerprint clear and associated to the facility can not be at the facility working until staff is finger print cleared and associated.

As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC-809 D page. Immediate Civil Penalty were assessed. An exit interview was conducted, and a copy of these LIC-809 reports, LIC 809-D page, LIC-421BG, and Appeals rights were provided to the Licensee/Administrator.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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 07/27/2023 04:15 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2023
Section Cited
CCR
87411(g)(1)

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87411(g)(2)Personnel Requirements - General
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(1) (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or
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Licensee stated that licensee will have (1) our of (4) facility staff get finger print clear. Licensee will also have (2) out (4) facility staff assoicted. Licensee will send finger print and association to LPA Lee by 08/01/2023 by 5:00 PM by end of day.

SACASCTransferRequest@dss.ca.gov by POC date 06/12/2023 by 5:00 PM
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Based on observations and record review, the licensee did not ensure 1 out of 4 facility staff located on the premises during the time of visit fingerprint cleared prior to working at the facility. It was also learned that 2 out 4 facilityn staff was also not associated to the facility prior to workinag at this faility, which poses/posed a immediate health, safety or personal rights risk to persons 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) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2