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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002859
Report Date: 02/23/2024
Date Signed: 02/23/2024 02:48:43 PM

Document Has Been Signed on 02/23/2024 02:48 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MOAIFACILITY NUMBER:
345002859
ADMINISTRATOR:FOWLER, CRAIG M.FACILITY TYPE:
740
ADDRESS:2633 CARDINAL COURTTELEPHONE:
(916) 844-5250
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 3CENSUS: 1DATE:
02/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Administrator and CaregiverTIME COMPLETED:
02:40 PM
NARRATIVE
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On 2/23/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a case management visit regarding a death report the department received on 2/20/2024. LPA met with Administrator, Craig Fowler, and explained the purpose of the visit.

Note: During time of LPA's visit, it was joined by Sacramento Metro Fire for fire clearance inspection. Facility was approved for change of ambulatory status to capacity of three- 2 ambulatory and 1 non-ambulatory. LPA will have license updated and mailed to facility once effective on system.

LPA and Administrator discussed that on 2/17/2024, R1 passed away in her sleep. Administrator reported R1 was on hospice services. Based on file review, LPA observed that R1 has a LIC 602 PHYSICIAN'S REPORT FOR RCFE on file that states R1 had non-ambulatory status. Additionally, LPA conducted a file review for R2 and observed R2's LIC 602 on file that states R2 has non-ambulatory status. Facility was originally licensed for three (3) ambulatory. End of visit, facility was cleared for fire clearance of one non-ambulatory. R2 has been relocated to a non-ambulatory approved room.

During today's visit, deficiencies was cited.

Exit interview and a copy of report and appeal rights provided to Administrator via email.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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 2
Document Has Been Signed on 02/23/2024 02:48 PM - It Cannot Be Edited


Created By: Cassie Yang On 02/23/2024 at 02:12 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: MOAI
FACILITY NUMBER: 345002859

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2024
Section Cited
CCR
87204(a)

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87204 Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license... This requirement is not met as evidenced by:
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Licensee has moved R2 to an approved non-ambulatory room.
Licensee will submit a statement of compliance to operate based on licensure.
POC due 2/24/2024.
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Based on file review, Licensee did not comply with the section cited above as R1 and R2 was accepted to the facility when facility was not licensed for non-ambulatory residents, which posed an immediate 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:Anthony Perez
LICENSING EVALUATOR NAME:Cassie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024


LIC809 (FAS) - (06/04)
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