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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701407
Report Date: 12/19/2024
Date Signed: 12/19/2024 03:59:33 PM

Document Has Been Signed on 12/19/2024 03:59 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:WHOLESOME ELDERLY ON TFACILITY NUMBER:
342701407
ADMINISTRATOR/
DIRECTOR:		ESTILLORE, NOELFACILITY TYPE:
740
ADDRESS:5332 T STREETTELEPHONE:
(916) 678-0268
CITY:SACRAMENTOSTATE: CAZIP CODE:
95819
CAPACITY: 6CENSUS: 2DATE:
12/19/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Juan RamirezTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 12/19/24, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a post-licensing visit. LPA was greeted by staff member, Juan Ramirez and explained the purpose of the visit. LPA asked that staff call the Facility Designated Administrator (FDA) Noel Estillore to inform them that CCL was present at this time. It was learned that Noel is no longer employed at the care home. Care staff then called licensee Chris Faamausili and a brief interview was conducted via telephone with the licensee Chris. LPA Lee explained the purpose of the visit. Per interview with licensee Chris will be the designated administrator. Chris also holds an active administrator certificate # 7011766740 and is valid until 06/08/2026. Licensee Chris will email LPA Lee documents to appoint himself as the administrator to the facility. Current census was 2.

This facility is licensed to served 6 non-ambulatory residents in room 1, 2, and 3. The facility second floor and detached garage are not for resident’s use. This facility also holds a hospice waiver for 6. There are currently no residents on hospice at this time. LPA reviewed 2 out of 2 resident files and 2 staff files. 1 out of 1 resident file is missing appraisal and needs and service. Furthermore, 1 out of 1 staff did not have a health screening and TB. Upon arrival, LPA Lee observed a strong smell of feces in the facility. A tour of the facility was conducted. LPA Lee observed feces on resident’s toilet seat. The feces appeared old and dried. Hot water temperatures were taken to ensure it was in the regulation of 105-120 degrees and it measured at 117.1 * F. Carbon monoxide and smoke alarms were present and were in working condition. Common areas for resident use were toured. Furniture and furnishings were observed to be present and in compliance. Grab bars and non-skid mats were present and functional. Resident bedrooms were toured. Furniture and furnishing were observed to be present and in good condition. A linen closet was located in the hallway and had sufficient number of linens at this time. The kitchen area was toured. Facility freezer and refrigerator showed to be functional.

Continued LIC 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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 9
Document Has Been Signed on 12/19/2024 03:59 PM - It Cannot Be Edited


Created By: Pang Lee On 12/19/2024 at 02:40 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: WHOLESOME ELDERLY ON T
FACILITY NUMBER: 342701407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above. LPA Lee observed the toxin in the laundry closet unlock which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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During today’s visit staff removed the toxins and locked it up in the storage closet. Administrator will review the regulation cited and provide LPA Lee a statement of acknowledgement by POC date 12/30/24 end of day 5:00 PM.
Type A
Section Cited
HSC
1559.269(a)(5)
§1569.269 Enumerated rights; severability
(a) Residents of residential care facilities for the elderly shall have all of the following rights:
(5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply in the section cited above. Both the refrigerator and pantry were locked which made it inaccessible to residents in care. This poses an immediate health, safety, or personal rights risk to persons in care.

POC Due Date: 12/30/2024
Plan of Correction
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During today's visit staff removed the lock from the refrigerator and unlocked all the pantry. Administrator will review the regulation cited and provide LPA Lee a statement of acknowledgement by POC date 12/30/24 end of day 5:00 PM.
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:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 12/19/2024 03:59 PM - It Cannot Be Edited


Created By: Pang Lee On 12/19/2024 at 02:40 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: WHOLESOME ELDERLY ON T
FACILITY NUMBER: 342701407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above. Upon arrival the facility had a strong feces order. It was observed in the resident's bath toilet having feces on the toilet seat and appeared to be old. This poses/posed a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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During today’s visit staff cleaned the resident’s toilet seat. Administrator will review the regulation cited and provide LPA Lee a statement of acknowledgement by POC date 12/30/24 end of day 5:00 PM.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. It was learned that staff 1 did not have a LIC 503 health screening and TB at the facility; however, per administrator S1 does have LIC 503 and will email to LPA Lee. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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Administrator agrees to locate S1's LIC 503 and TB and email to LPA Lee. Administrator will review the regulation cited and provide LPA Lee a statement of acknowledgement by POC date 12/30/24 end of day 5:00 PM.
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:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 12/19/2024 03:59 PM - It Cannot Be Edited


Created By: Pang Lee On 12/19/2024 at 02:40 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: WHOLESOME ELDERLY ON T
FACILITY NUMBER: 342701407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(2)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA Lee reviewed 2 staff files and it didn't have any documentations of continued annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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Admistrator agrees to enroll staff in training and provided continue annual training to facility staff. Administrator will email training certificate to LPA Lee. Administrator will review the regulation cited and provide LPA Lee a statement of acknowledgement by POC date 12/30/24 end of day 5:00 PM.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. R1's file did not have appraisal and needs and service in R1's file. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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Administrator will complete an appraisal and needs and service for R1. The documents will be email to LPA Lee. Administrator will review the regulation cited and provide LPA Lee a statement of acknowledgement by POC date 12/30/24 end of day 5:00 PM.
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:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 12/19/2024 03:59 PM - It Cannot Be Edited


Created By: Pang Lee On 12/19/2024 at 02:40 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: WHOLESOME ELDERLY ON T
FACILITY NUMBER: 342701407

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. R1's file did not have LIC 602/medical assessment in R1's file. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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Administrator will ensure that a LIC 602/medical assessment is conducted for R1 or a schedule appointment. The documents will be email to LPA Lee. Administrator will review the regulation cited and provide LPA Lee a statement of acknowledgement by POC date 12/30/24 end of day 5:00 PM.
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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


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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: WHOLESOME ELDERLY ON T
FACILITY NUMBER: 342701407
VISIT DATE: 12/19/2024
NARRATIVE
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LPA Lee observed both the refrigerator and pantry locked and made inaccessible to residents in care at this time. LPA observed 2-day perishable and 7-day nonperishable food supply and it was sufficient at this time. The fire extinguisher, located in the kitchen area, was serviced on 12/18/24 and is in compliance at this time. Second floor of the facility was toured. This facility has a centralized medication cabinet that was observed to be locked and made inaccessible to the residents. First aid kit was observed to be present and contained all the required components at this time. Toxins were observed not locked and made accessible to residents in care. Exterior grounds of this facility were toured. Perimeter fence and gates were observed to be functional and in good repair at this time. Detached garage was also toured.

Per California Code of Regulations (CCR) - deficiencies are being cited on the attached LIC 809 -D. Appeal Rights provided. Failure to correct deficiencies may result in civil penalties. An exit interview was held with
staff Juan Ramirez and a copy of the report was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
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