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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005716
Report Date: 03/05/2024
Date Signed: 03/05/2024 05:21:04 PM

Document Has Been Signed on 03/05/2024 05:21 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:FOUNTAINS SENIOR CARE SECOND LLC, THEFACILITY NUMBER:
317005716
ADMINISTRATOR:MACIUCA, ESTERAFACILITY TYPE:
740
ADDRESS:5422 CASA GRANDE AVENUETELEPHONE:
(916) 470-1416
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY: 6CENSUS: 4DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Estera Maciuca and Claudia OlveraTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday March 5, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA Parks reviewed resident (4) and staff files (2). LPA did not observe a current physicians report (dated 11/30/2022) for R1 who had a Dementia diagnosis. All staff files contained the required paperwork and training.

LPA Parks, Estera, and Claudia toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, garage, and backyard. In the areas toured, there were no health or safety violations observed.

Facility was clean and well organized. All required posting were observed.

See 809D for citation issued. Exit interview conducted. A copy of this report was emailed to the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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 03/05/2024 05:21 PM - It Cannot Be Edited


Created By: Melissa Parks On 03/05/2024 at 02:44 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: FOUNTAINS SENIOR CARE SECOND LLC, THE
FACILITY NUMBER: 317005716

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of four which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Licensee will obtain a current physicians report for R1
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:Melissa Parks
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
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