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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701084
Report Date: 05/02/2024
Date Signed: 05/02/2024 12:19:51 PM

Document Has Been Signed on 05/02/2024 12:19 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:R & E SENIOR CARE, INC.FACILITY NUMBER:
342701084
ADMINISTRATOR/
DIRECTOR:		EMILY PASCUAFACILITY TYPE:
740
ADDRESS:5231 OLIVEHURST WAYTELEPHONE:
(916) 895-4357
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 5DATE:
05/02/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:30 AM
MET WITH:Emily PascuaTIME VISIT/
INSPECTION COMPLETED:
12:30 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
Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 5/2/24 at 7:30a. LPA met with Emily Pascua and Randmelvin L Pozon regarding todays visit. During the complaint visit on 5/1/24, LPA provided a LIS Roster and reviewed it with the Licensee. It was discussed that the staff in pending status should not be working until cleared and associated. Licensee stated they were not hiring Staff # 2 (S2) as the finger prints continue to be in pending status. LPA inquired about the staff working during this shift. Both Emily Pascua and Randmelvin L Pozon stated that they are the caregivers working now and the others left. LPA went outside to the front yard and saw 2 caregivers leaving the facility from the side of the home. LPA requested to see their identifications and requested to see the staff files from Emily. Both S1 and S2 stated they did not have identification. LPA requested again some form of identification. They both presented passports. Upon further review, S1 is finger print cleared and associated to the facility. Licensee admitted that although it was stated yesterday that S2 would not be hired because of pending status, S2 has worked in the facility for 1 year. This information was confirmed by S2 during this visit. Community Care Licensing does not have any previous staff roster printouts which contained S2's name. Licensee stated they do not have previous rosters which are shredded once updated. S2 provided copies of live scan and finger print documents dating back to 2023 which indicate she was cleared. Licensee has submitted an email to the Guardian Department to inquire about the pending status.

A review of the facility files for S1 and S2, they were observed to be either missing or incomplete. Both did not include pertinent Licensing forms. LPA provided a copy of the LIC311F Records to be maintained at the facility-Residential Care Facility for the Elderly.
Civil Penalty assessed in the amount of $500.00. (See LIC421IM) Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; additional civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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 3
Document Has Been Signed on 05/02/2024 12:19 PM - It Cannot Be Edited


Created By: Victoria Brown On 05/02/2024 at 09:40 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: R & E SENIOR CARE, INC.
FACILITY NUMBER: 342701084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/03/2024
Section Cited
CCR
87355(f)

1
2
3
4
5
6
7
Criminal Record Clearance
Violation of Section 87355(e) shall result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the department.
1
2
3
4
5
6
7
Administrator shall submit an email to the Guardian Department inquiring what are the next steps.
POC Cleared during this visit by observation of email sent.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: LIS and Guardian does not include S2's name as associated and finger print cleared
Based on Confirmation from Licensee and S2, S2 has been working for 1 year in the facility.
This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
You are hereby notified that an immediate civil penalty of $500.00 is assessed for a violation that resulted in staff working with finger print clearance and association.
(See LIC421IM)
Type A
05/03/2024
Section Cited
CCR87412(a)-(h)

1
2
3
4
5
6
7
Personnel Records
The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
1
2
3
4
5
6
7
Licensee shall submit a plan on when all documents will be completed and placed in staff files. Fax by POC due date
8
9
10
11
12
13
14
This requirement is not met as evidenced by: records review
Based on observation during visit, records are either missing or incomplete
This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
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:Stephen Richardson
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/02/2024 12:19 PM - It Cannot Be Edited


Created By: Victoria Brown On 05/02/2024 at 11:19 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: R & E SENIOR CARE, INC.
FACILITY NUMBER: 342701084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/03/2024
Section Cited
CCR
87207

1
2
3
4
5
6
7
False Claims

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
1
2
3
4
5
6
7
Licensee shall submit a statement that in-service training will be conducted with all staff regarding the Title 22 regulations "False Claims".
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on Confirmation from Licensee and S2, that S2 has been working for 1 year in the facility. In addition, S1 and S2 stated that they did not have any identification.
This poses an immediate 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

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.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3