347005713-5-1-2025-27-AS-PLEE-DG9QMB-20250501121715

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005713
Report Date: 05/01/2025
Date Signed: 05/01/2025 12:17:47 PM

Document Has Been Signed on 05/01/2025 12:17 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:	DANIEL RESIDENTIAL CARE HOME LLC		FACILITY NUMBER:	347005713
ADMINISTRATOR/ DIRECTOR:	DIALA, JOYCE		FACILITY TYPE:	740
ADDRESS:	4295 AMAPOLA WAY		TELEPHONE:	(916) 717-3263
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	05/01/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:48 AM
MET WITH:	Joyce Diala		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE

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On 05/01/25 Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with care staff Helen Agbiriogu and Irene Iberi and explained the purpose of the visit. Care staff called the facility designated administrator (FDA) Joyce Diala to informed that CCLD was present in the facility. FDA arrived approximately an hour later. Care staff and administrator assisted with today’s visit. Administrator certificate # is 6035237740 and will expire on 08/05/25. The current census is 5 with 2 facility staff.

The facility is a single-story building licensed to serve six (6) residents. Rooms 1 and 3 are approved for non-ambulatory residents, while room 2 is designated for ambulatory residents only. LPA Lee conducted an inspection of the physical plant, including but not limited to the common areas, kitchen, dining area, resident bedrooms and bathrooms, laundry room, garage and outdoor courtyards, to ensure compliance with Title 22 regulations. The facility was observed to be clean, odor-free, and in good repair. Resident bedrooms were properly furnished with appropriate bedding and adequate lighting. No bodies of water were observed on the premises. During the kitchen tour, LPA Lee observed a sufficient supply of food, including a seven-day supply of non-perishable and a two-day supply of perishable items. The hot water temperature in the resident bathroom sink measured 110.3°F, which falls within the regulatory range of 105°F to 120°F. Grab bars and non-slip mats in the bathrooms were secure and in good condition. Smoke and carbon monoxide detectors were found to be operational and in compliance with fire safety requirements. The facility's fire extinguisher, located in the hallway, was purchased on 10/27/24. Per administrator Diala, the last fire drill was conducted on in April 2025 and that it was not documented. LPA Lee advised that fire drill needs to be conducted every 3 month and should be documented.

Continued LIC 809-C

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Pang Lee	TELEPHONE: (916) 508-9726
	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

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: DANIEL RESIDENTIAL CARE HOME LLC	FACILITY NUMBER: 347005713
	VISIT DATE: 05/01/2025

NARRATIVE

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A public telephone is available in the common area, and all required documents and postings were visibly displayed; however, LPA Lee observed PUB 475 poster is not the correct sized and LPA Lee advised administrator that the poster needs to be in the size of 20” by 26”. The facility thermostat was set to 73°F at the time of the inspection. Toxic cleaning agents were stored in a locked hallway closet, inaccessible to residents. Sharp knives were observed secured in a locked cabinet. Medications were stored securely and were inaccessible to residents. LPA Lee reviewed medications for all six (5) residents and verified that the medication administration records (MARs) were complete and accurate. The first aid kit was inspected and contained all required supplies.

Resident and staff files were requested and reviewed. All six (5) resident files were found to be complete. LPA Lee reviewed staff 1 (S1)’s file and it was not complete. S1 did not have current 20 hours of continual training, and first aid/CPR certificate had expired. LPA Lee requested to review the administrator’s file, and it was learned that the administrator’s file is not at the facility; therefore, LPA Lee was not to review the administrator’s file. A review of staff records confirmed that all individuals requiring background checks were fingerprint cleared and associated with the facility.

The following documents will be email to LPA by 05/08/25 end of day 5:00 PM:

(1) LIC 308 Designation of Administrative Responsibility

(2) Copy of Administrator Certificate

(4) LIC 610 Current Emergency Disaster Plan

(5) Proof of Current Liability Insurance

(6) LIC 500 Current Personnel Report

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with administrator Diala and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/01/2025 12:17 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DANIEL RESIDENTIAL CARE HOME LLC	FACILITY NUMBER: 347005713
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.625(b)(2)

§1569.625(b)(2) Staff training; legislative findings; contents (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training… (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626… This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review S1 did not have current training in S1’s file and first aid/CPR had expired on 07/12/23, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/15/2025
	Plan of Correction
1 2 3 4	Administrator agrees to ensure that all facility staff has continued 20 hours of training annually. Administrator will review the regulation and provide LPA Lee a statement of acknowledgement of reading and understanding the regulation cited. Administrator will also email LPA Lee all staff first aid/CPR certificate and 10 hours of continual training for 2025. POC due by 05/15/25 end of day 5:00 PM.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Pang Lee	TELEPHONE: (916) 508-9726
	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/01/2025 12:17 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DANIEL RESIDENTIAL CARE HOME LLC	FACILITY NUMBER: 347005713
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87412(g)

87412(g) Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review administrator’s file was not in the facility for LPA Lee to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/08/2025
	Plan of Correction
1 2 3 4	Administrator agrees to ensure that all staff files are readily available for review. Administrator will email LPA Lee at pang.lee@dss.ca.gov administrator’s documents in the file for review. Administrator will review the regulation and provide LPA Lee a statement of acknowledgement of reading and understanding the regulation cited. POC due by 05/08/25 end of day 5:00 PM.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Pang Lee	TELEPHONE: (916) 508-9726
	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

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