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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700588
Report Date: 10/24/2024
Date Signed: 10/24/2024 03:10:52 PM

Document Has Been Signed on 10/24/2024 03:10 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:SIGNATURE LIVING ON WINDING WAYFACILITY NUMBER:
342700588
ADMINISTRATOR/
DIRECTOR:		AFABLE, SCOTTFACILITY TYPE:
740
ADDRESS:6258 WINDING WAYTELEPHONE:
(916) 812-0944
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 6DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Placida DeVeraTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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On 10/24/2024, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a required annual inspection utilizing the inspection tool. LPA net with Assistant Administrator and explained the purpose of the visit.

Today's visit, LPA and Assistant Administrator conducted a tour of the facility to ensure the health and safety of residents in care. LPA observed facility to have the required posters posted in the common areas. LPA observed facility to have two days of perishable and seven day of nonperishable food present. LPA observed knives and toxins to be locked and secured. LPA observed the facility to have ample supply of PPEs and linens. LPA observed facility to have active Administrator Certificate posted, and a copy of facility liability insurance.

File review conducted for three personnel records and three resident records.

LPA observed the Fire Drill binder and did not observe any documentation of fire and earthquake drills conducted in 2024. Additionally, LPA observed LIC610E to be last reviewed in August 2023 but not conducted for 2024.

Annual inspection completed with Assistant Administrator, please see LIC 809D.

Exit interview and a copy of the report and appeal rights provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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 10/24/2024 03:10 PM - It Cannot Be Edited


Created By: Cassie Yang On 10/24/2024 at 03:00 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: SIGNATURE LIVING ON WINDING WAY
FACILITY NUMBER: 342700588

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above as Fire Drill binder did not have any drills documented for the year of 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Licensee is to submit a plan/ schedule to LPA of when fire and earthquake drills are to be conducted to be in compliance.
POC is due 11/1/2024.
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:Anthony Perez
LICENSING EVALUATOR NAME:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
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