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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005711
Report Date: 12/12/2024
Date Signed: 12/12/2024 02:28:36 PM

Document Has Been Signed on 12/12/2024 02:28 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:ZENCAR SERVICES INCFACILITY NUMBER:
347005711
ADMINISTRATOR/
DIRECTOR:		RHYMES, KATHYFACILITY TYPE:
775
ADDRESS:3125 DWIGHT ROAD 500TELEPHONE:
(916) 737-5207
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 30CENSUS: 15DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Kathy RhymesTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with director Kathy Rhymes and explained the purpose of the visit.

LPA Moleski reviewed five client files (C1-C5) and five staff files (S1-S5). C1 and C2 did not have admission agreements on file. C1 started attending program about a month ago, according to Rhymes. C2 was admitted in 2019, per their client file.

LPA Moleski was provided an incident report by Rhymes. The incident report described the use of a restraint by Rhymes and two other staff members (S1-S7) on 12/9/24. According to the incident report, a client (C5) became aggressive and physically assaulted Rhymes and another staff member (S1) by pulling their hair, attempting to bite them, and kicking them in the legs. Rhymes and S1 each held C5's arms and moved C5 toward a wall, while S7 held C5's legs, according to the incident report. LPA Moleski requested this facility's emergency intervention plan in order to assess whether or not this restraint was performed in accordance with the design of this program. Rhymes said this facility does not have an emergency intervention plan as part of its program design.

LPA Moleski toured the facility with Rhymes and inspected common areas, the kitchen, and bathrooms. Furniture and furnishings were sufficient to meet the needs of clients. The facility temperature was 69 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 118 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, a fully-charged fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed locked closets for the storage of cleaning solutions. LPA Moleski interviewed three staff members (S2, S5, S6). This facility is hereby cited per 22 CCR Sections 82068(a) and 82122(a). An exit interview was held with Rhymes. Appeal rights and a copy of this report were left with Rhymes.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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Document Has Been Signed on 12/12/2024 02:28 PM - It Cannot Be Edited


Created By: Vincent Moleski On 12/12/2024 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ZENCAR SERVICES INC
FACILITY NUMBER: 347005711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82122(a)
"If staff use, or it is reasonably forseeable that staff will use, manual restraint or seclusion, the applicant or licensee shall be responsible to ensure an Emergency Intervention Plan is developed and approved by the Department prior to the use of such techniques."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, a manual restraint was used on a client experiencing aggressive behaviors without having an emergency intervention plan to dicate the means of said restraint, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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Licensee agrees to submit a written understanding of the aforementioned requirement by POC due date. Licensee will develop, at a later date, an emergency intervention plan and will submit it to LPA Moleski for approval.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/12/2024 02:28 PM - It Cannot Be Edited


Created By: Vincent Moleski On 12/12/2024 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ZENCAR SERVICES INC
FACILITY NUMBER: 347005711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(a)
Admission Agreements
(a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, there were no admission agreements for two clients, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2024
Plan of Correction
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Licensee agrees to provide LPA Moleski new admission agreements for these clients by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
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