<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002853
Report Date: 12/20/2023
Date Signed: 12/20/2023 11:09:07 AM

Document Has Been Signed on 12/20/2023 11:09 AM - 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SIGNATURE LIVING ON CAMELIA AVENUEFACILITY NUMBER:
315002853
ADMINISTRATOR:OCAMPO, JESSEFACILITY TYPE:
740
ADDRESS:904 CAMELIA AVETELEPHONE:
(916) 899-5880
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: DATE:
12/20/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:CaregiverTIME COMPLETED:
11:15 AM
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
On 12/20/23, Licensing Program Analyst (LPA), Kevin Mknelly, conducted a plan of correction visit (POC) inspection for deficiencies issued on 12/14/23. LPA was greeted by caregiver.

On 12/14/23 deficiencies were cited for failure to provide for wound care as needed for R1.
Licensee has not submitted the POC for the citation that was due by 12/15/23.
LPA spoke by phone with Nerryrose Kreig, designated responsible staff, and explained that civil penalties are being issued and that the plan of correction continues to be due.

LPA also met with R1. R1 stated they are receiving regularly scheduled Home Health and that care at the home is meeting their needs.

No additional deficiencies are cited for today's visit.

An exit interview was conducted with caregiver. A copy of the report was provided.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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 1