347005649-9-24-2026-27-AS-SLOZ-DY8SYK-20260924141740

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005649
Report Date: 09/24/2026
Date Signed: 09/24/2026 02:17:48 PM

Document Has Been Signed on 09/24/2026 02:17 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:	STA. RITA'S ELDER CARE		FACILITY NUMBER:	347005649
ADMINISTRATOR/ DIRECTOR:	FLOWERS, RITA C.		FACILITY TYPE:	740
ADDRESS:	8982 MERLOT WAY		TELEPHONE:	(916) 689-5828
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95829
CAPACITY: 5		CENSUS: 4	DATE:	09/24/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Administrator- Rita Flowers		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On September 24, 2026, at 12:30 PM, Licensing Program Analyst (LPA) Sulma Lopez arrived unannounced at the facility to conduct an annual required inspection. LPA Lopez met with Staff 1 (S1) Evangeline Ujano and explained the purpose of today's visit. The Administrator 1 (A1) Rita Flowers arrived shortly after. The facility is licensed for five (5) non-ambulatory residents. There are currently four (4) residents who reside at this facility. The facility has an approved hospice waiver for three (3). One (1) out of the three (3) hospice placements are occupied. At 12:45 PM, LPA conducted record reviews of 4 staff and 4 resident files. Staff files were observed to contain Health Screening, First Aid Certificates, Background Clearance, and updated training records. Resident files contained Health Screening, TB Test Records, and current Needs and Services Plans. At 1:15PM, LPA conducted a medication review. Medications were stored in a locked cabinet. The facility uses a MAR sheet to record all dispensed medication to residents. At 1:40PM, LPA toured the facility with A1. The facility kitchen was observed to be clean and free of hazards. The facility stores sharps and toxins in locked cabinets and drawers in the kitchen. The facility contained at least 2 days of perishable food items and at least 7 days of non- perishables. The kitchen appliances were observed to be operational. LPA toured the dining room and living room areas which were observed to be clean and free of odors. Enough seating was present to accommodate the current census. Continued on LIC 809-C.

Arielle Pascua
Sulma Lopez
	DATE: 09/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: STA. RITA'S ELDER CARE	FACILITY NUMBER: 347005649
	VISIT DATE: 09/24/2026

NARRATIVE

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The LPA toured the resident bedrooms. The bedrooms were clean and free of hazards. The rooms were furnished with beds, night stands, and dressers which were in good repair.

The facility restrooms were clean and sanitary. The showers contained grab bars and slip-resistant mats for resident safety. The restrooms also contained hand washing supplies.

The LPA conducted a visual inspection of the staff room from the entrance. The LPA toured the laundry room which contained detergent in locked cabinets.

The facility utilizes the garage as a storage room and office area. LPA toured the exterior of the facility. The exterior walkways were free of obstructions. The side exit and perimeter fence were in good repair.

The facility temperature was 75 degrees. The facility's hot water temperature was 111 degrees. The facility's fire extinguishers were serviced annually on August 13, 2026.

The LPA requested the following documents to be emailed/ faxed to the Regional Office within 15 days:
- LIC 500 Personnel Report, LIC 308 Designation of Facility Representative, LIC 610E Emergency and Disaster Plan, and a copy of the Liability Insurance Certificate.

As a result of this annual inspection, the facility was in compliance and no deficiencies were cited. An exit interview was conducted and a copy of this report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Sulma Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

LIC809 (FAS) - (06/04)

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