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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920037
Report Date: 02/04/2025
Date Signed: 02/04/2025 02:48:02 PM

Document Has Been Signed on 02/04/2025 02:48 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SAPPHIRE SENIOR CAREFACILITY NUMBER:
315920037
ADMINISTRATOR/
DIRECTOR:		TULENINOVA, NATALIAFACILITY TYPE:
740
ADDRESS:667 GRIDER DRIVETELEPHONE:
(279) 900-8903
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 4DATE:
02/04/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Natalia TuleninovaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 2/4/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Administrator .

On 1/25/25, R1 experienced bleeding into their catheter. R1 was on Hospice and hospice responded to a call. Bleeding restarted after Hospice service. R1 was sent to an area hospital for care. R1 passed away in hospital on 1/26/25.

LPA reviewed R1 records and interviewed Administrator. LPA received copies of requested records.
LPA requested Administrator gather additional details and timelines for events of 1/25/25 for R1's incident and resubmit the death report with requested details.

LPA to contact R1's representative and Hospice for additional information

As a result of today’s inspection, no deficiencies were noted at this time .



Report reviewed. Copy of report provided to Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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