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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701338
Report Date: 07/16/2024
Date Signed: 07/16/2024 03:48:31 PM

Document Has Been Signed on 07/16/2024 03:48 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:KEVINBERG CARE HOMEFACILITY NUMBER:
342701338
ADMINISTRATOR/
DIRECTOR:		PARAMO, FERNANDO PAZFACILITY TYPE:
740
ADDRESS:8351 LANCRAFT DR.TELEPHONE:
(916) 382-9472
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 3DATE:
07/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Fernando ParamoTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 7/16/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a case management visit. LPA met with Administrator Fernando Paramo and explained the purpose of the visit.

The purpose of this case management visit is to follow up on an audio/video recording LPA Truong received from Esther on 6/9/24 to ensure personal rights were being followed. Previously, LPA Truong and Investigator Barajas made a visit to the facility on 6/4/2024 and interviewed R1. In the recording, resident (R1) can be heard alleging LPA Truong and IB’s Investigator Juan Barajas of being rude to her and of trying to hurt her, and take away her money, house, and her property.

During today’s visit, LPA Truong interviewed staff (S1) and Administrator Fernando Paramo. Based on staff interviews, it was learned that S1 has not seek permission from R1 to record nor did R1 gave consent for S1 to record. Staff S1 stated that R1 is aware that S1 is recording. Resident R1 is no longer residing in this facility to provide a statement.

As a result, deficiencies were cited during today’s visit pursuant to Title 22 rules and regulations, Health and Safety Codes.

An exit interview was conducted, a copy of this report, LIC 809-D and appeal rights were left at the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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 07/16/2024 03:48 PM - It Cannot Be Edited


Created By: Tung Truong On 07/16/2024 at 03:11 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: KEVINBERG CARE HOME
FACILITY NUMBER: 342701338

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/23/2024
Section Cited
CCR
87468.1(a)(1)

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Personal Rights of Residents in All Facilities
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This is not met as evidenced by:
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Licensee shall review Title 22 Regulations, Section 87468.1 Personal Rights of Residents in All Facilities and submit a written statement stating knowledge of, understanding of regulation 87468.1. Correction due 7/23/24.
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Based on interview and record review, the facility did not comply with the section cited above. The facility did not seek R1’s permission nor have R1’s consent to recording. This poses a potential health and safety risk to 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:Tung Truong
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024


LIC809 (FAS) - (06/04)
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