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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005632
Report Date: 10/31/2023
Date Signed: 10/31/2023 11:46:29 AM


Document Has Been Signed on 10/31/2023 11:46 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:ESPINOZA CARE HOME 2FACILITY NUMBER:
347005632
ADMINISTRATOR:ESPINOZA,ALFREDO/MIRANDAFACILITY TYPE:
735
ADDRESS:380 ARCADE BLVDTELEPHONE:
(916) 544-9003
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY:4CENSUS: 3DATE:
10/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alfredo EspinozaTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced and met with Alfredo Espinoza administrator and explained the reason for the visit.

LPA Ivey Canady reviewed Alta Regional Center Facility notice of Sanctions dated 9/22/2023. On 09/08/2023, Alta Regional discovered that the facility was in violation of California Code of Regulations, Title 17. LPA Ivey Canady reviewed 3 resident files for R1, R2 and R3. MAR files for R3 have been corrected since Alta Regional's unannounced visit and no additional medication errors were observed. Alta Sanctions have not been lifted. LPA Ivey Canady received a copy of corrected MAR file for R3.

Administrator provided LPA Ivey Canady with staff training documentation regarding required personnel training, however, LPA Ivey Canady did not receive a facility staff sign in sheet for the training.

Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations are being cited on the attached LIC-809D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was held and a copy of the report was given to administrator Alfredo Espinoza.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
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 10/31/2023 11:46 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ESPINOZA CARE HOME 2
FACILITY NUMBER: 347005632

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2023
Section Cited
CCR
80075(b)

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80075 Health Related Services - (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:
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Licensee stated there will be a PRN Medication Record for R1 will be signed and dated by a physician on 11/2/2023 and will provide LPA a copy no later than (NLT) 11/30/2023. Licensee also will provide additional staff medication training documentation to LPA NLT 11/30/2023
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Based on record review and interviews, the facility did not ensure residents medication had been properly administered. This poses a health and safety risk for persons in care.
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Type B
10/31/2023
Section Cited
CCR85065(f)

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85065 Personnel Requirements (f) (f) The licensee shall ensure that all direct services to clients requiring specialized skills are performed by personnel who are licensed or certified to perform the service. This requirement was not met as evidenced by:
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Licensee stated the correct personnel training courses will be completed and certificates and proof of courses will be forwarded to LPA NLT 11/30/2023.
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Based on record review, the Licensee did not ensure staff had obtained the appropriate training in pursuant to Title 22 regulations as it relates to Title 17 regulations. This poses a health and safety risk for 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) 263-4723
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
LIC809 (FAS) - (06/04)
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