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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700556
Report Date: 09/10/2025
Date Signed: 09/10/2025 11:33:03 AM

Document Has Been Signed on 09/10/2025 11:33 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:DELA PAZ CARE HOMEFACILITY NUMBER:
342700556
ADMINISTRATOR/
DIRECTOR:		DELA PAZ, LOURDESFACILITY TYPE:
740
ADDRESS:6712 GREEN ASH CTTELEPHONE:
(916) 560-3232
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 4CENSUS: 3DATE:
09/10/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Lourdes de la Paz, Administrator TIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Evie Sloan, DSP and Dennis Abadilla, Administrator Designee. LPA stated the reason for the inspection. A case management inspection is being conducted today to follow up on (2) allegations made through a formal complaint on June 2, 2025, at a related facility. During the investigation, it was determined that the (2) staff/individuals referenced in the allegations did not work or were not present at the related facility, but at this facility. The (2) allegations and determinations are as follows:

Uncleared adult(s) are present in the facility. The complaint alleged that staff (S1) was working at the facility without the required fingerprint clearances. Documentation was reviewed confirming that (S1) received a fingerprint clearance on May 1, 2024 and was associated to the facility on this same day.

The allegation also stated individual (S2) who was not employed at the facility, stayed at the facility beginning in March 2025 and was not fingerprint cleared. The investigation revealed that (S2) entered the facility on/around March 10, 2025 and stayed there until as late as on/around May 18, 2025. The Administrator indicated that (S2) stayed at the facility for approximately two weeks. Staff (S3) stated (S2) was visiting the facility off and on starting on March 10, 2025.

Review of department records showed that (S2) did not receive fingerprint clearance and was not associated to this facility, or any other licensed facility. Based on information obtained, this portion of the allegation is substantiated and a citation and penalties are being issued.

*cont on 809C-1..
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2025
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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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)
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Document Has Been Signed on 09/10/2025 11:33 AM - It Cannot Be Edited


Created By: Sabrina Calzada On 09/10/2025 at 09:35 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: DELA PAZ CARE HOME
FACILITY NUMBER: 342700556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2025
Section Cited
CCR
87355(d)(3)

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87355 Criminal Record Clearance
(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. (3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. This requirement was not met as evidenced by:
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Licensee/Administrator agree to read Regulation 87355 and submit a statement of understanding. Also submit fingerprints for processing for (S2), if they plan to be present in the facility in the future. Request (S2) complete an LIC508 also prior to being present in the facility again.
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Based on record review and interviews conducted, the Licensee did not ensure that individual (S2) received a finger print clearance prior to residing at the facility, on/around March 10, 2025, which posed an immediate health and safety risk to residents in care.
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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.
Maribeth Senty
NAME OF LICENSING PROGRAM MANAGER:
Sabrina Calzada
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: DELA PAZ CARE HOME
FACILITY NUMBER: 342700556
VISIT DATE: 09/10/2025
NARRATIVE
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809C-1.. Allegation: Residents were exposed to a staff member with Tuberculosis. The allegation states that individual (S2) was visiting and staying with staff (S3) and (S2) was recently discharged from the hospital for having a diagnosis of Tuberculosis (TB). The allegation states (S3) and the clients are/were possibly exposed to TB.

During the investigation, LPA spoke with (2) public heath nurses in June 2025 regarding (S2) possibly being treated and hospitalized due to having TB. One nurse provided information on (S2's) TB status beginning on 5/20/25 and confirmed that (S2) was "approved to be discharged to a skilled nursing" on 5/29/25, after being hospitalized in San Diego County starting on 5/20/25. This nurse confirmed there was "no active TB" upon discharge but "(S2) has a history of TB from the Philippines" and (S2) completed all their treatments.

A second public health nurse, in Sacramento County, confirmed that (S2) was in San Diego and Sacramento County was planning on seeing them again but (S2) was in the process of relocating to another area. The nurse stated that (S2) was not considered to have active TB; however, a "final determination is still needed" from her office, asserting (S2) "would not have had an active disease in March 2025" and the county was planning to see them. The nurse explained that (S2) could have had residual findings related to a positive test and "collective sputem on (S2)" which is not considered an active case.

The Administrator stated (S2) is currently residing out of state and was recently hospitalized due to other medical conditions unrelated to TB. The Administrator stated that it's very common for individuals from (S2's) country of origin to test positive initially for TB after taking a Quantiferon TB test and then follow up with a chest X-ray which shows a negative result for TB.

All staff and clients (4) at this facility had a TB test given from June 2025 through August 2025. All results provided showed a negative result, if not initially from the Quantiferon test, then from a follow up X-ray. (S3) was advised to have a follow up X-ray done on 6/16/25, and was not found to have active TB.

Based on information obtained, this allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview. Copy of report provided.
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC809 (FAS) - (06/04)
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