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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002853
Report Date: 10/23/2024
Date Signed: 10/24/2024 08:21:56 AM

Document Has Been Signed on 10/24/2024 08:21 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/
DIRECTOR:		OCAMPO, JESSEFACILITY TYPE:
740
ADDRESS:904 CAMELIA AVETELEPHONE:
(916) 899-5880
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 6DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Atunaisa "Jacob" SogariTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 10/23/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator was unavailable to assist.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is very clean and residents stated they are happy with care. LPA provided advisories regarding various topics. Citations issued for documentation of emergency training and drills.

LPA reviewed 6 resident files. Files are complete and well organized. LPA advised more thorough Needs and Services and Home Health care plans. PIN 22-24-ASC provided.

LPA reviewed 2 staff files. Increased training documentation needed

Deficiencies are being cited as a result of todays inspection.


Exit interview conducted with Caregiver. Due to Printer malfunction, copy of report and appeal rights are to be emailed to Licensee
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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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Document Has Been Signed on 10/24/2024 08:21 AM - It Cannot Be Edited


Created By: Kevin Mknelly On 10/23/2024 at 01:32 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIGNATURE LIVING ON CAMELIA AVENUE
FACILITY NUMBER: 315002853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(b)
Other Provisions
(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on records review, the licensee did not comply with this section based on 2 of 2 staff records that did not have training on the facility's emergency and disaster plan. This posed a potential risk to residents
POC Due Date: 11/06/2024
Plan of Correction
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Licensee will submit proof of all current care stafftarining on the facility's emergency procedures by the POC date of 11/6/24
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and record, the licensee did not comply with the section cited above in quarterly emergency drills have not been recored which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2024
Plan of Correction
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Proof of drills including all caregivers during the shifts for which they regularly work will be submitted by the POC date of 11/06/24.
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:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/24/2024 08:21 AM - It Cannot Be Edited


Created By: Kevin Mknelly On 10/23/2024 at 02:30 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIGNATURE LIVING ON CAMELIA AVENUE
FACILITY NUMBER: 315002853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)
Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)(D)ny incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.


This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview the licensee did not comply with the section cited above infor R4's recent incident and hospitalization which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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Licensee will submit a procedure and accountable staff to ensure all reportable incidents are reported timely by the POC date of 10/30/24
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:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
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