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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005733
Report Date: 08/22/2024
Date Signed: 08/22/2024 03:00:49 PM


Document Has Been Signed on 08/22/2024 03:00 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:SIGNATURE LIVING RCFEFACILITY NUMBER:
347005733
ADMINISTRATOR:FLORES, HAZELFACILITY TYPE:
740
ADDRESS:7315 POCKET ROADTELEPHONE:
(916) 346-4128
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Diana BonuccelliTIME COMPLETED:
03:30 PM
NARRATIVE
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On 8/22/24 at 1:15pm Licensing Program Analyst (LPA) Kevin Gould arrived at Signature Living RCFE for the purpose of conducting a required 1 year annual inspection. LPA met with staff, Diana Bonuccelli and together conducted a tour of the home.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA observed there are two used needle disposal containers that are not in compliance as the bins are overfilled and cannot be closed to protect the health and safety of staff members. The facility is not in compliance with Title 8, Section 5193 concerning bloodborne pathogens.

LPA measured the water temperature, temperature measured at 113 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA reviewed staff files and observed one resident with a diagnosis of dementia did not have a current and up to date physician's report as the most recent physician's report was dated February 2023.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 9020 client roster and current administrator certificate.

Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
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 3


Document Has Been Signed on 08/22/2024 03:00 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: SIGNATURE LIVING RCFE
FACILITY NUMBER: 347005733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(f)(2)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations the licensee did not comply with the section cited above as two used needle disposal containers that are not in compliance as the bins are overfilled and cannot be closed to protect the health and safety of staff members which poses an immediate health, safety or personal rights risk to staff visitors and residents in care.
POC Due Date: 08/23/2024
Plan of Correction
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Facility will obtain a new needle disposal container and submit a written plan of correction indicating the steps facility will take to ensure the needle disposal meets regulations and policies in place to ensure the violation does not reoccur.
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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/22/2024 03:00 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: SIGNATURE LIVING RCFE
FACILITY NUMBER: 347005733

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onrecord review the licensee did not comply with the section cited above in one out of three resident files reviewed which shows a resident with dementia that did not have a current pysician's report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Facility will obtain a new physician's report for resident by the POC due date.
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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3