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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003007
Report Date: 11/06/2025
Date Signed: 11/06/2025 05:01:42 PM

Document Has Been Signed on 11/06/2025 05:01 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:STA. RITA'S SENIOR CAREFACILITY NUMBER:
347003007
ADMINISTRATOR/
DIRECTOR:		FLOWERS, RITA C.FACILITY TYPE:
740
ADDRESS:8978 MERLOT WAYTELEPHONE:
(916) 689-5828
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 5CENSUS: 5DATE:
11/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:RIta FlowersTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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On 11/6/2025, Licensing Program Analyst (LPA) Cynthia Tamayo visited the facility unannounced to conduct a case management visit- deficiencies. LPA Tamayo met with care staff Joel Cruz (S2), and explained the purpose of the visit. S2 called facility administrator, Rita flowers (S1) via phone call, S1 stated they are in the Philippines and will return 11/10/25. The most current LIC 308 lists two staff whom are no longer working at the facility, S1 stated the visit may be conducted with S2.

The current census for today was four. There were currently two staff present. The facility is licensed to serve five (5) non-ambulatory residents age ranges 60 years old and above. Five (5) non-ambulatory may only occupy bedroom #1-5. Hospice waiver approved for three (3) residents.

The purpose of this visit is to follow up on deficiency observed on 9/18/25, in which staff were signing off medication on the Medication Administration Records (MARs) in advance of actual administration for all residents.

LPA observed the all medications listed on the MARS sheet for R1 was signed off from 9/1/2025 - 9/18/2025, even though R1 moved out on 9/5/2025. S2 admitted to signing off medication records in advance, which constitutes a deficiency per California Code of Regulations, TITLE 22.

LPA was reviewing resident records in which it was found that LIC 602 Physicians report for R4, indicated they are bedridden. S1 and S2 stated R4 can turn on their own and a request for an updated LIC 602 will be requested on this day.
CONTINUED ON 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2025
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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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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Document Has Been Signed on 11/06/2025 05:01 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 11/06/2025 at 09:40 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: STA. RITA'S SENIOR CARE
FACILITY NUMBER: 347003007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2025
Section Cited
CCR
87465(d)(3)

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 87465 Incidental Medical and Dental Care (d)... for a prescription or nonprescription PRN medication. .. facility staff designated by the licensee, shall ... assist the resident with self-administration ...(3) The date and time ... medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the
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Licensee will submit a plan to ensure all staff responsible for medication assistance will receive a retaining on medication administration and accurately maintaining medication administration records (MARs) by POC due date
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This requirement was not met as evidenced by records review and interviews: review of medication administration record (MAR) dated September 2025 revealed that staff signed for medications as given prior to the actual administration. Additionally, S2 did not complete the MAR on 11/6/25 immediately after administering the medications to residents in care. Interview with staff confirmed that they pre-sign MARs to "save time". The practice constitute inaccurate medication documentation and fails to ensure that medication records reflect the actual time and date of administration, as required by Title 22. This poses an immediate health and safety risk to residents in care, as medications may be missed, duplicated, or administered incorrectly
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Type B
11/14/2025
Section Cited
CCR87405(a)

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87405 Administrator - Qualifications and Duties (a) .... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility...
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Licensee will submit an updated LIC 308 by POC due date.
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This requirement was not met as evidenced by LIC 308 listing two individuals whom are no longer staff at the facility. S1 and S2 stated administrator was out of the country during this visit but available to staff via phone call for any staff or resdeint needs.
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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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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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: STA. RITA'S SENIOR CARE
FACILITY NUMBER: 347003007
VISIT DATE: 11/06/2025
NARRATIVE
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LPA observed R4 was laying down in their bed and they were able to reposition on their own but needed assistance to transferring onto a wheel chair. LPA reviewed bedridden and fire clearance regulations with S1 and S2, S1 stated an updated LIC 602 will be requested today.

Additional Technical Violations were provided along with resources from Technical Assistance Program (TSP) including "Hospice" and "Pressure Wounds" guides.

As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with S2 and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC809 (FAS) - (06/04)
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