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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701172
Report Date: 08/14/2025
Date Signed: 08/14/2025 12:06:30 PM

Document Has Been Signed on 08/14/2025 12:06 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:YOUNG AT HEART RCFE NO.5 INCFACILITY NUMBER:
342701172
ADMINISTRATOR/
DIRECTOR:		SISAYAN, ISAGANIFACILITY TYPE:
740
ADDRESS:8039 CAYMUS DRIVETELEPHONE:
(916) 681-3689
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 6CENSUS: 6DATE:
08/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Glenda MolinyaweTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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On 8/6/2025, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct a Required - 1 Year visit. LPA met with administrator, Glenda Molinyawe and explained the purpose of the visit. Administrator Isagani Sisaya is out on vacation. Current LIC 308 designated S1 as Designated Facility Responsible person.

Administrator Certificate # for Isagani Sisayan is 7002475740 and expires 10/23/2025. Administrator Certificate # for Glenda Molinyawe is 6052178740. The facility is approved for five (5) ambulatory residents (Age range 60 and over) in which five (5) may be non-ambulatory and one (1) bedridden in bedroom #1 only. Hospice waiver for 2 has been granted. There is currently one resident on hospice.

LPA toured the physical plant was conducted with S2 to ensure residents’ health and safety and the facility is in compliance with Title 22 regulations. The following was observed:

KITCHEN: Appliances and fixtures were clean and functional. The facility had ample supply of perishable and non-perishable food. Meals are prepared by the Staff. Refrigerator temperature was at 45 degrees F and freezer temperature was at 0 degrees F. Knives and other sharps are locked inaccessible in a drawer. Kitchen and house cleaning supplies are stored in a locked cabinet located under the sink.

COMMON AREAS: Common areas include the Living Room and Dining Room. All furniture was observed to be clean and in good condition with enough seating for six residents . There was space to accommodate both indoor and outdoor activities. LPA noted an Activity Calendar and activity storage in the entrance bulletin board. One (1) fire extinguisher was observed throughout the common area and was last serviced on 09/24/2025. Combination smoke detectors and carbon monoxide detectors were working and operational.
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NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2025
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 4
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: YOUNG AT HEART RCFE NO.5 INC
FACILITY NUMBER: 342701172
VISIT DATE: 08/14/2025
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EXTERIOR: Exterior passageways were clean and clear of any obstructions. There is a covered patio area for client and visitor use with furniture observed to be in good condition. Clients are supervised at all times when they are outside. There is one (1) gates with a self-latching mechanism for persons to exit the backyard in emergencies.

BEDROOMS: LPA inspected facility bedrooms. The facility has six(6) total resident. All bedrooms were observed to contain furniture, bedding and linens within regulation. Extra linens are stored in the hallway cabinet. Client bedrooms had no visible hazards observed.

BATHROOMS: All bathrooms were observed to be clean and sanitary, and supplied with paper and hygiene products. Water temperature was tested and both measured at 114.6 degrees F.

MEDICATION REVIEW: LPA reviewed medications which are centrally stored in a locked cabinet in the hallway. All medications were stored and administered in compliance with regulation.

RECORD REVIEW: LPA reviewed six (6) resident file records. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. Resident files reviewed contained all required documents. LPA discussed the following with S1: (1) The requirement to do a re-appraisal and/or updated physicians report (LIC 602) when there is a change of condition for residents, such as hospice status. (2) Also, hospice status does not automatically constitute bedridden status, appropriate fire clearance would be required for changing a room to bedridden status.

LPA reviewed three (3) staff records during today's visit. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All staff records reviewed were in compliance at the time of the visit.

RESIDENT INTERVIEWS: LPA Tamayo interviewed two residents who were able to respond verbally, residents voiced no concerns with their quality of care, and said they receive all assistance when needed.

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NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: YOUNG AT HEART RCFE NO.5 INC
FACILITY NUMBER: 342701172
VISIT DATE: 08/14/2025
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INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility's infection control plan as well as the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are within regulation. Both documents were observed to be complete and recently updated. Personal Protection Equipment (PPE) and extra emergency supplies, including emergency food and water, are stored in the garage.

The following documents will be email to LPA by 8/21/2025 end of day (5:00 PM):
(1) LIC 610 Current Emergency Disaster Plan
(2) Proof of Current Liability Insurance
(3) Surety Bond (if applicable)
(4) LIC 309 Administrator Organization

As a result of this annual visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted with Glenda Molinyawe, and a copy of these LIC 809 reports were provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
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