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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920075
Report Date: 02/06/2025
Date Signed: 02/06/2025 11:46:00 AM

Document Has Been Signed on 02/06/2025 11:46 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PURE CARE HOMEFACILITY NUMBER:
345920075
ADMINISTRATOR/
DIRECTOR:		MESLOUB, SID ALIFACILITY TYPE:
740
ADDRESS:6355 PERRIN WAYTELEPHONE:
(916) 254-1412
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator, Sid Ali Mesloub TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains arrived on 02/06/25 to conduct the annual inspection. LPA met with Administrator, Sid Ali Mesloub and explained the purpose of today's visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed medications of two (2) residents comparing with physician orders. LPA reviewed two (2)residents files and two (2) staff files.

LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Hot water temperature was observed to be 111 degrees F, which is within the regulation range of 105-120 degree.

LPA requested a copy of the LIC308, LIC 500, LIC610E and current liability insurance to be sent to the Department by 02/21/25.

Deficiencies were observed and cited per Title 22, CCR Regulations as listed on LIC 809-D. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today.

Exit interview conducted. Copy of this report and appeal rights were provided.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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 5
Document Has Been Signed on 02/06/2025 11:46 AM - It Cannot Be Edited


Created By: Talwinder Bains On 02/06/2025 at 11:12 AM
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: PURE CARE HOME
FACILITY NUMBER: 345920075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff interview and record review, it was learnt that residents (R1,R2) has Medical Assesment indicating thier status as Non-ambulatory and Bedridden (both) but facility has Fire Clerance for 6 non-ambulatory residents only. Additionaly facility has one fire extinguisher which was last serviced in 2023, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Licensee shall send a letter of understading of this Regulation by 02/07/25 to department. Furthermore, Licensee shall apply for Bedridden Fire Cleranace OR shall relocate R1, R2 to another place to meet thier fire status requiemnets within 30 days. Licensee shall ensure to have working fire extinguisher by POC date-02/07/25.
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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/06/2025 11:46 AM - It Cannot Be Edited


Created By: Talwinder Bains On 02/06/2025 at 11:12 AM
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: PURE CARE HOME
FACILITY NUMBER: 345920075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

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 documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff interview and record review, the licensee did not comply with the section cited above as residents (R1,R2) have medical assesment (LIC602) in thier files which were not filled/signed by thier medical professionals, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Licensee shall ensure to have medical assesments completed/signed by thier medical proffesionals for all residents ,including R1,R2 and shall notify Department once completed. POC date is 03/05/25.
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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
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