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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700194
Report Date: 11/04/2025
Date Signed: 11/05/2025 08:30:35 AM

Document Has Been Signed on 11/05/2025 08:30 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:NORRIS SENIOR HOMEFACILITY NUMBER:
342700194
ADMINISTRATOR/
DIRECTOR:		VERA, NAZARINA DEFACILITY TYPE:
740
ADDRESS:4184 ENGLE ROADTELEPHONE:
(916) 571-5650
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: 4DATE:
11/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Nazarina De Vega and Rona GeronimoTIME VISIT/
INSPECTION COMPLETED:
04:15 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
On November 04, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Nazarina Vega and explained the purpose of today's visit.

The facility Administrator holds current certificate and expires on August 07, 2025. The facility is licensed for six non-ambulatory clients. There are currently four residents who reside at this facility. The facility has an approved hospice waiver for five. Zero out of the five hospice placements are occupied.

The LPA Martinez toured the facility with Rona Geronimo, 2025, at 2:00 PM.

LPA Martinez reviewed four resident files; six staff files; and two medication files. Facility staff files were complete. Four out of four resident files were missing reappraisals. Resident 1's (R1) medication order, medication bottle label, and Medication Administration Record (MAR) have different dispense instructions for Famotidine 40 MG. Medication order states, "take 1 tablet by mouth daily at bed time." The MAR states, "take 1 tablet daily." The medication bottle label states, "take 1 tablet by mouth 2 times a day." R1's Ferosul 325 MG bottle label states, "take 1 tablet by mouth every other day or as directed." However, the bottle was altered to state, "everyday" with a black marker. The facility is not following R3's melatonin 10 MG medication order. R3' MAR indicates that care staff have been administering one 10 MG tablet daily. However, the Melatonin tablet being administered daily is 5 MG. In addition, the MAR does not indicate that two 5 MG tablets are being administered daily.

Continued..

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2025
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 6
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)
Page: 2 of 6
Document Has Been Signed on 11/05/2025 08:30 AM - It Cannot Be Edited


Created By: Avelina Martinez On 11/04/2025 at 10:16 AM
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: NORRIS SENIOR HOME
FACILITY NUMBER: 342700194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2025
Section Cited

1
2
3
4
5
6
7
87463(a) Reappraisals: The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first...This requirement was not met as evidence by: based on observation
8
9
10
11
12
13
14
file review, and interview, 4 out of 4 residents did not have an updated reappraisal. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/05/2025 08:30 AM - It Cannot Be Edited


Created By: Avelina Martinez On 11/04/2025 at 11:17 AM
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: NORRIS SENIOR HOME
FACILITY NUMBER: 342700194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2025
Section Cited

1
2
3
4
5
6
7
87465(h)(4) Incidental Medical and Dental Care: The following requirements shall apply to medications which are centrally stored:All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a
8
9
10
11
12
13
14
prescription label. This requirement was not met as evidence by: based on file review/observation, the licensee did not ensure R3 Ferosul 325 MG med-bottle label was correct. R3's Med- bottle was altered. This posed a potential health and safety risk to R3.
8
9
10
11
12
13
14
Facility staff agrees to email training documents and medication audit findings and pictures of new medication bottle label to LPA Martinez by POC Date: 11/18/2025 by 5:00 PM.

Type B
11/18/2025
Section Cited

1
2
3
4
5
6
7
87465(a)(4) Incidental Medical and Dental Care: The licensee shall assist residents with self-administered medications as needed.The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: based on observation
8
9
10
11
12
13
14
file review, the licensee did not ensure facility staff assisted R1 and R3 with medications . This posed a potential health and safety risk to R1
8
9
10
11
12
13
14
Facility staff agrees to email training documents and medication audit findings to LPA Martinez by POC Date: 11/18/2025 by 5:00 PM.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/05/2025 08:30 AM - It Cannot Be Edited


Created By: Avelina Martinez On 11/04/2025 at 11:59 AM
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: NORRIS SENIOR HOME
FACILITY NUMBER: 342700194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2025
Section Cited

1
2
3
4
5
6
7
87465(e)(2) Incidental Medical and Dental Care: For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank... and a label on the medication...The exact dosage.
8
9
10
11
12
13
14
Based on file review and observation, the Licensee did not ensure R1 and R3's written orders and medication lables contained the correct medication order information. This posed a potential health and safety risk to R1 and R3.
8
9
10
11
12
13
14
Facility staff agrees to email training documents and medication audit findings to LPA Martinez by POC Date: 11/18/2025 by 5:00 PM.
Type B
11/18/2025
Section Cited

1
2
3
4
5
6
7
87465(a)(6) Incidental Medical and Dental Care:A plan for incidental medical and dental care shall be developed by each facility:When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
8
9
10
11
12
13
14
This requirment was not met as evidence by: based on observation and file reivew, the licensee did not ensure dosages of medications on MARs were maintained. This posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Facility staff agrees to email training documents and medication audit findings to LPA Martinez by POC Date: 11/18/2025 by 5:00 PM.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: NORRIS SENIOR HOME
FACILITY NUMBER: 342700194
VISIT DATE: 11/04/2025
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
26
27
28
29
30
31
32
R3's MAR states, "Buspirone 10 MG- 1.5 tablet 3 times daily." The Buspirone medication bottle label states, "15 MG- take 1 tablet by mouth 3 times a day." The medication order states, "15- MG take 1 tablet by mouth 3 times a day." R3's MAR states, "Calcium Citrate 1 tablet daily." The Calcium Citrate bottle has a label, and the dosage is 700 MG. The Calcium Citrate medication order states, "250 MG- take 1 tablet by mouth daily.

Facility fire extinguisher was last inspected on July 25, 2025. The facility smoke and carbon detectors were in good repair. The exterior emergency exit gate was in good repair. The facility has a first aid kit. The facility has a locked closet for medication storage. Resident bedrooms, common areas, kitchen, bathrooms, and laundry room were furnished and sanitary. The facility has a public telephone located at the kitchen. The facility has an adequate food supply. The facility water temperature measured at 105 degrees and the facility temperature measured at 72 degrees.

The exterior of the home is clear of debris, and the resident patio is furnished and in good repair. The facility shed is used as storage room. The facility does not have interior or exterior cameras. The facility sketch is current. Bedroom one is occupied by one resident Bedroom two not occupied. Bedroom 3 is occupied by one resident. Bedroom 4 is a staff room. Bedroom 5 is occupied by two residents. LPA Martinez will continue to follow up facility resident bedroom layout and fire clearance request.

As a result of this annual inspection visit, the following deficiencies were cited, per California Code of Regulations, Title 22 and Health and Safety Code: 87465(e)(2) Incidental Medical and Dental Care; 87465(a)(6) Incidental Medical and Dental Care; 87465(h)(4) Incidental Medical and Dental Care; 87465(a)(4) Incidental Medical and Dental Care; and 87463(a) Reappraisals.

An exit interview was conducted, and a copy of the 809 report, 809D-Page, and appeals right were given to the facility at the end of this visit.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6