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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002993
Report Date: 02/07/2025
Date Signed: 02/07/2025 04:08:36 PM

Document Has Been Signed on 02/07/2025 04:08 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:MAHALOHA CARE LLCFACILITY NUMBER:
345002993
ADMINISTRATOR/
DIRECTOR:		RIVERA, GERALD JOHN G.FACILITY TYPE:
740
ADDRESS:8223 TWIN OAKS AVETELEPHONE:
(916) 910-9652
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 5DATE:
02/07/2025
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Gerald Rivera, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 2/7/2025, at 2:00 PM, a Non-Compliance Conference meeting was held with Sacramento North Regional Office via Microsoft Teams Meeting.

Present in the meeting was Licensee, Gerald Rivera, Regional Manager (RM) Alycia Rayner, Licensing Program Manager (LPM) Maribeth Senty, Licensing Program Manager (LPM) Troy Ordonez, and Licensing Program Analyst (LPA) Sabrina Calzada.

Topic discussed during this meeting were:

An incident that occurred on 12/31/24, at another facility where the Administrator worked, and how (8) residents were left unattended and unsupervised, for approximately (1.5) hours. The incident was discussed in detail and how it relates to Administrator qualifications, duties and responsibilities.

The licensee was in agreement with the drafted non-compliance plan as outlined in LIC 9111.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is also being cited on the 809-D page.

An exit interview was conducted and a copy of this report and appeal rights will be provided to the facility via email.

A copy will be signed and returned to CCLD.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
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 2
Document Has Been Signed on 02/07/2025 04:08 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 02/07/2025 at 03:28 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: MAHALOHA CARE LLC
FACILITY NUMBER: 345002993

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2025
Section Cited
CCR
87408(a)(6)

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87408 Denial or Revocation of a Certificate (a) The Department may deny or revoke any administrator certificate for violation of licensing regulations or on any of the following grounds:
(6) The certificate holder engaged in conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement is not met as evidenced by:
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The Licensee/Administrator agree to submit all documents, and complete any training or tasks listed on page 3 of the LIC9111, dated 2/7/25, that was discussed during the meeting on 2/7/25.

All documents related to the above to be submitted to CDSS by email/fax by 2/17/25.
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Based on interviews conducted and documentation reviewed, the Licensee did not ensure that the Administrator did not engage in conduct inimical, on the evening of 12/31/24, at another CDSS licensed care facility, when (8) residents were left unattended for approximately an hour and a half, which posted 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:Maribeth Senty
LICENSING EVALUATOR NAME:Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2025


LIC809 (FAS) - (06/04)
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