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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701561
Report Date: 04/25/2025
Date Signed: 04/25/2025 11:23:46 AM

Document Has Been Signed on 04/25/2025 11:23 AM - 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:PACIFIC HILLS CARE HOME, LLCFACILITY NUMBER:
342701561
ADMINISTRATOR/
DIRECTOR:		TIEN, LIT AFACILITY TYPE:
740
ADDRESS:8676 PACIFIC HILLS WAYTELEPHONE:
(916) 687-1207
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 4CENSUS: 0DATE:
04/25/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Lit TienTIME VISIT/
INSPECTION COMPLETED:
08:36 AM
NARRATIVE
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On 4/25/25, at 830, Licensing Program Analyst(LPA) Noel Wolf Petersen and Licensing Program Manager(LPM) Liza King, arrived announced to do a prelicensing inspection. They were met by administrator Lit Tien and staff Chris Sinon, and explained the purpose of the visit.

The Physical Plant was inspected, including but not limited to the recreation areas, living room, storage, hallways, client bedrooms, client bathrooms, and kitchen. The facility was found to be in physical compliance with the required furnishings and cleanliness. No bodies of water were observed.

The first aid kit was inspected and found to have the required items, the fire extinguishers was stored properly and checked on 11/21/24 and found in compliance. The bathrooms had the resident temperature at 117.3*F, between the required 105-120. The trash cans were clean and secured, the food storage had 2 days of perishables, and 7 days of non-perishable food as per regulation. Sharps and toxics were stored in locked containers, medication storage was ready and available.

In a subsequent prelicensing inspection the LPA is recommending that the the following are available for inspection/review: surety bond, that have bedbug casing for the mattresses, storage in the garage is clear of sharps and toxics, that the sample staff and client records are available, that the admission agreement, infection control plan, and plan of operation are ready to review, that they have and emergency kit with items and sample documentation ready to go, posters should be of correct dimension, updated LIC 308 and 500, notification for audio visual surveillance on the front door, all personal belongs removed from the facility, and fresh fruit and vegetables available for clients.

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NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2025
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 3
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: PACIFIC HILLS CARE HOME, LLC
FACILITY NUMBER: 342701561
VISIT DATE: 04/25/2025
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The facility is ready to be licensed, however prior to accepting any clients into care a reinspection must occur. The assigned anaylst is Pang Lee 916-508-9726.

The facility is pending vendorization to provide services to elderly 4I individuals.

During this time, the licensee agreed to the following:
  • they will maintain their fees with licensing
  • they will notify community care licensing before a client arrives
  • they will maintain control of the property
  • a mandatory reinspection will occur before accepting residents
  • they will maintain contact information by phone and email.


An exit interview was conducted and the report read and delivered to the staff. COMP III was not conducted on this date, the licensee is an already existing licensee with a home operating in the Regional Office and in compliance.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC809 (FAS) - (06/04)
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