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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700570
Report Date: 04/07/2023
Date Signed: 04/07/2023 04:46:31 PM

Document Has Been Signed on 04/07/2023 04:46 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SEN'S CAREGIVINGFACILITY NUMBER:
342700570
ADMINISTRATOR:PRASAD, INDRA SENFACILITY TYPE:
740
ADDRESS:5250 SHORTWAY DRTELEPHONE:
(916) 471-9145
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 3DATE:
04/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Indra Prasad, Licensee/AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conduct a case management visit regarding deficiencies learned through a complaint investigation. LPA met with Administrator Indra Prasad and explained the purpose of today’s visit.

The purpose of the case management was to address concerns learned through a complaint investigation on 4/7/2023. It was learned that resident R1 AWOL’D from the facility on 2/17/2023; however, the facility did not report to Licensing as required.

Deficiencies were observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code.

An exit interview was conducted, a copy of this report, LIC 809-D and appeal rights were provided to Administrator. Failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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 04/07/2023 04:46 PM - It Cannot Be Edited


Created By: Tung Truong On 04/07/2023 at 03:55 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SEN'S CAREGIVING
FACILITY NUMBER: 342700570

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2023
Section Cited
CCR
87211(a)(1)

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Reporting Requirements
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...any; and disposition of the case.
This requirement is not met as evidenced by:
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Licensee shall submit by fax a statement that all written incidents will be submitted timely by fax.
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Based on interviews and records review, the licensee did not submit a written incident report to Licensing as required. Administrator confirmed with LPA that an incident report was not submitted. This poses an immediate health, safety, or personal rights risk to residents in care.
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Type A
04/10/2023
Section Cited
CCR87405(d)(2)

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Administrator Qualifications: If the licensee is also the administrator, all requirements for an administrator shall apply including…knowledge and ability to conform to applicable laws and regulations.
This requirement is not met as evidenced by:
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Administrator agrees to take training including but not limited to the following: Title 22 regulations, effective communication and record keeping and documentation. Training topics and dates shall be submitted by POC date, 4/10/2023.
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Based on interviews and record review, the licensee did not follow reporting requirement as required in Title 22 regulation, which poses 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.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Tung Truong
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
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