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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701248
Report Date: 05/15/2024
Date Signed: 05/15/2024 03:28:34 PM

Document Has Been Signed on 05/15/2024 03:28 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:SACRAMENTO SENIOR LIVING IIFACILITY NUMBER:
342701248
ADMINISTRATOR/
DIRECTOR:		LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:34 LOMA MAR CTTELEPHONE:
(530) 710-5707
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 5DATE:
05/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Salote LewisTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a case management visit on 5/15/2024. LPA met with Administrator Salote Lewis and stated the purpose of today’s visit.

The purpose of today's visit is in response to deficiencies observed during a complaint visit on 5/9/24. On 5/9/24, LPA observed a staff room with a bed; however, the facility sketch does not indicated that there is a staff room. Based on record review, it was learned that the room was initially designated as an office. The facility has converted the office into a staff room for the live-in staff without notifying the Department.

LPA informed the Administrator that if the facility chooses not to have a staff room, a plan of operation addendum shall be sent to Licensing indicating awake staff at all times.

Deficiencies were 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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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 05/15/2024 03:28 PM - It Cannot Be Edited


Created By: Tung Truong On 05/15/2024 at 11:22 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: SACRAMENTO SENIOR LIVING II
FACILITY NUMBER: 342701248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2024
Section Cited
CCR
87305(b)

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87305(b) Alterations to Existing Building or New Facilities: The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists.
This requirement is not met as evidence by:
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The Licensee shall read regulation 87305 and submit a signed declaration of understanding to LPA by POC due date.

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Based on the LPA's findings, the facility has converted the office into a staff room. The facility failed to submit the plan to licensing, which poses a potential Health, Safety risk to residents in care.
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The Administrator has removed the bed and no longer uses the room as a staff room.

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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: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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