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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700570
Report Date: 07/05/2023
Date Signed: 07/05/2023 10:01:35 AM

Document Has Been Signed on 07/05/2023 10:01 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
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:
07/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ekshay ShahilTIME COMPLETED:
11:19 AM
NARRATIVE
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On July 07, 2023, Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee arrived at facility unannounced to conduct a case management visit. LPAs met with Ekshay Shahil and explained the purpose of the visit.

The purpose of the visit today, is in response to a learned deficiency from 27-AS-20230329164139 complaint investigation The 27-AS-20230329164139 complaint investigation revealed staff 1 fell asleep during their Shift. Furthermore, S1 was the only care staff on shift. As a result, residents in care were not provided care and supervision, and this incident was an immediate health and safety risk to all residents in care.

An immediate $500.00 civil penalty shall be assessed on July 05, 2023 for Violation of California Code of Regulations Section: Basic Services 87464(f)(1).

The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code.


An exit interview was conducted, and a copy of this 809 report, 809-D report, LIC 421IM form, and appeals rights were provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2023
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 07/05/2023 10:01 AM - It Cannot Be Edited


Created By: Avelina Martinez On 07/03/2023 at 04:30 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: 07/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/06/2023
Section Cited
CCR
87464(f)(1)

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Basic Services 87464(f)(1): Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement was not met as evidence by:
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Facility staff agrees to conduct care and supervision training for all staff by POC date 07/06/2023. Facility will email training documents to LPA Martinez by POC date 07/06/2023 by 5:00 PM.
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Based on interviews, it was learned staff 1 (S1) fell asleep during a shift, and S1 was the only caregiver work. This posed an immediate health and safety risk to all 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:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023


LIC809 (FAS) - (06/04)
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