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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881045
Report Date: 01/13/2023
Date Signed: 01/13/2023 02:04:53 PM

Document Has Been Signed on 01/13/2023 02:04 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:SAHARIA CARE HOMES INC.FACILITY NUMBER:
361881045
ADMINISTRATOR:MATHUR, BHARTIFACILITY TYPE:
735
ADDRESS:7531 STONEY CREEK DRIVETELEPHONE:
(909) 856-9921
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 4CENSUS: 4DATE:
01/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Jay RubaTIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Anna Bueno and Michelle Echeverria conducted an unannounced visit to this facility regarding a report of capacity limitations. LPAs met with staff Diego Blanco and Jay Ruby, house manager. The following is a summary of the incident:

On 1/05/2023, LPA Anna Bueno received a call from administrator (AD) Sachin Mathur regarding Client 1 (C1) that was placed in the home. LPA advised AD to submit an LIC 200 to request a capacity change. The Department received the LIC 200 on 1/11/2023 requesting for a capacity change.

Refer to LIC809-D for deficiency cited. An exit interview was conducted where this report (LIC 809), LIC 809-D, LIC421IM, and appeal rights were discussed, and copies were provided to Jay Ruba
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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 01/13/2023 02:04 PM - It Cannot Be Edited


Created By: Anna Bueno On 01/13/2023 at 01:38 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SAHARIA CARE HOMES INC.
FACILITY NUMBER: 361881045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/13/2023
Section Cited
CCR
80010(a)

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A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement was not met as evidenced by:
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Administrator submitted a request for capacity change as of 1/11/2023. Licensee shall notify the Department after a visit from local Fire Department no later than the next business day.
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LPAs reviewed LIC602, Physician's Report, and confirmed Client 1 is non ambulatory. This facility is licensed for ambulatory only. This poses an immediated health and safety risk to clients 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:Nedra Brown
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023


LIC809 (FAS) - (06/04)
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