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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920184
Report Date: 02/18/2025
Date Signed: 02/18/2025 05:09:33 PM

Document Has Been Signed on 02/18/2025 05:09 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:RC PREMIER VILLA IIFACILITY NUMBER:
345920184
ADMINISTRATOR/
DIRECTOR:		CABRERA, ZADELFACILITY TYPE:
740
ADDRESS:8138 ROBERT CREEK COURTTELEPHONE:
(925) 567-8181
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 3DATE:
02/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:50 PM
MET WITH:MJ Cabrera, House Manager TIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with MJ Cabreara, House Manager, stating the reason for today's inspection. Administrator, Zadel Cabrera, was contacted and indicated she was unavailable during the inspection.
The Department received (2) incident reports (LIC624) on February 14, 2025, reporting the following:

The LIC624 from February 12, 2025 states that at 1:45 pm, (R1) stated they wanted to go to the store and left the house. The report notes that a caregiver tried to stop resident from leaving as they cannot leave the facility unattended but the resident stated they can do what they want. The facility contacted the police to stop (R1) but the police stated they cannot stop the resident. The facility called 9-1-1 to take resident to the hospital for a change in condition due to increased confusion, but the resident refused to go . The police stated resident can make their own choices since they are not conserved. (R1) agreed to return to the care home providing the care giver take them to the store.

The LIC624 from February 13, 2025 states around 1:00 pm, (R1) was found to be missing from the home and the police was contacted after an immediate search was done. (R1) was found walking in the rain and agreed to return to the facility if caregiver took them to the store again. (R1) was brought back and attempted to leave one more time that afternoon, when waiting for the ambulance, around 4:00 pm. The Administrator contacted LPA promptly after (R1) was observed missing and stated that (R1) was smoking on the back patio, and staff went to care for another resident. When the staff had returned (10) minutes later, resident had left the facility.

(R1's) physician's report, dated August 14, 2024, indicates that (R1) is not able to leave the facility unattended due to her mental status. The Administrator was contacted by the emergency room physician after (R1) was sent there to advise that (R1) would be transferring to a secured memory care.

Per California Code of Regulations, Title 22, Chapter 6, Division 8, the following (1) citation is issued on the 809-D page. Exit interview. Copy of report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/18/2025 05:09 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 02/18/2025 at 04:39 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: RC PREMIER VILLA II
FACILITY NUMBER: 345920184

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/19/2025
Section Cited
CCR
87705(d)

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87705 Care of Persons with Dementia.
(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions.
This requirement is not met as evidenced by:
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Licensee/Administrator agrees to conduct staff training on preventing elopements, change the auditory device so it can better alert staff, consider using staff pagers so staff can be alerted. Also facility will consider using a tracking device, approved by the local police, for any other residents that have a high risk of elopement, provided it doesn't violate resident rights.
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Based on information submitted to the Department on February 13, 2025, the Licensee did not ensure that (R1) was unable to leave the facility unassisted, which posed an immediate health and safety risk to residents in care. The front door does have an auditory alert; however, staff did not hear it when it sounded.
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House Manager to submit a training plan (date to be trained) and confirm possible solutions by tomorrow, 2/19/25. Also indicate by 2/19/25 estimated resolution.

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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: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
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