550307827-8-20-2025-27-AS-ELIM-DKQTQH-20250820145558

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 550307827
Report Date: 08/20/2025
Date Signed: 08/20/2025 02:56:12 PM

Document Has Been Signed on 08/20/2025 02:56 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:	SIERRA FOOTHILLS RESIDENTIAL CARE, INC.		FACILITY NUMBER:	550307827
ADMINISTRATOR/ DIRECTOR:	KATHERINE BELFIELD		FACILITY TYPE:	735
ADDRESS:	20470 BAY MEADOWS DRIVE		TELEPHONE:	(209) 533-3708
CITY:	SONORA	STATE: CA	ZIP CODE:	95370
CAPACITY: 14		CENSUS:	DATE:	08/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:45 AM
MET WITH:	Katherine, Belfield, Adminsitrator		TIME VISIT/ INSPECTION COMPLETED:	03:00 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	At 10:50 AM on 8/19/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by the Administrator. The LPA identified herself, explained the purpose of the visit, and an interview followed. The Administrator accompanied the LPA on a tour of the facility. This facility is licensed to serve fourteen ambulatory residents. It is a six-bedroom, 5-bathroom house located in a residential area. The census was fourteen residents; none were home at the time of this inspection. There was two staff on duty when the LPA arrived, both of whom have criminal background clearances. The LPA toured the inside of the house, including the bedrooms, bathrooms, kitchen, two dining rooms, two living rooms, and laundry room. The entire house was clean, odor-free, and pest-free. The windows and window screens were in good repair. The required documents were posted in the common areas. The LPA inspected the fire alarm and detection system. There were smoke alarms in every bedroom and three in common areas. There were four fire alarm pull stations that were connected to an alarm box in the staff office. The Administrator tested the alarm system, and it was in working order. The Administrator tested the carbon monoxide detector in the hallway and it was in working order. There were four fire extinguishers located throughout the house. The fire extinguishers were last serviced on 11/19/2024 by Cisco Fire. The LPA observed documentation of monthly disaster drills. (Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

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: SIERRA FOOTHILLS RESIDENTIAL CARE, INC.	FACILITY NUMBER: 550307827
	VISIT DATE: 08/20/2025

NARRATIVE

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The LPA toured the six bedrooms and four bathrooms. There are four double-occupancy bedrooms and two single-occupancy bedrooms. Each bedroom contained the required furniture, including bed, bedside table, lamp, dresser, and chair. Each double-occupancy bedroom has an exit door to the outside. The bedrooms were odor-free and pest-free. The LPA toured the bathrooms. The bathrooms were clean and odor-free. The LPA measured the water temperature at a bathroom sink; the temperature of the water was 109 degrees Fahrenheit, within the required range.

The LPA toured the kitchen. The kitchen was clean, the appliances were operable, and the trashcan had a lid on it. There was a seven-day non-perishable and two-day perishable supply of food located in the kitchen refrigerator-freezer and cabinets. Sharp objects were kept locked in a lower kitchen drawer and cleaners were kept in a locked cabinet beneath the sink. The LPA toured the two dining rooms and two living rooms. The LPA observed tables and enough seating for residents in these rooms. There is a large TV in one living room and a closet full of games, movies, and puzzles in the other living room. The LPA observed that the thermostat was set at 68 degrees Fahrenheit. The LPA toured the laundry room. This room contained laundry machines and two refrigerator/freezers, including one for resident food and one for the household. The laundry room contained locked cabinets with cleaners.

The LPA toured the front, back, and side yards. There was shaded tables and chairs in the front yard. The facility has plans to enclose the back patio to make a work-out room. A garden is being added to a side yard. The LPA observed two sheds. One was used for resident storage, and one was used for storage of non-perishable food. The walkways were obstruction-free.

The LPA inspected the central medication storage area, which was a separate office kept locked and inaccessible to residents. Each resident's medication was stored in a separate storage unit and all medication was in its original containers. The LPA observed the electronic-based medication administration record (MAR), doctor’s medication prescriptions, and the medication for two residents and found that all three were consistent. There was a first aid kit that contained all the required items.

(Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

LIC809 (FAS) - (06/04)

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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: SIERRA FOOTHILLS RESIDENTIAL CARE, INC.	FACILITY NUMBER: 550307827
	VISIT DATE: 08/20/2025

NARRATIVE

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The LPA reviewed records for two residents and two staff and found the records to be complete. Both staff had criminal background clearances and current first aid/CPR certifications. The Administrator’s certificate was valid.

The LPA requested that updated copies of the following documents be submitted to Licensing by 9/3/2025 at ellen.lindstrom@dss.ca.gov.

(1) LIC 308 Designation of Facility Responsibility
(2) Copy of a current Administrator Certificate
(3) LIC 610D Emergency Disaster Plan
(4) Proof of Liability Insurance
(5) LIC 500 Personnel Report
(6) LIC 309 Administrative Organization

As a result of this inspection, no deficiencies were cited. The facility was in compliance with California Code of Regulations (CCR), Title 22, Division 6.

An exit interview was conducted with the Administrator, to whom a copy of this LIC809 report was provided. Their signature below confirms receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

LIC809 (FAS) - (06/04)

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