347003007-2-11-2026-27-AS-CTAO-DR7TNL-20260211135255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003007
Report Date: 02/11/2026
Date Signed: 02/11/2026 01:53:25 PM

Document Has Been Signed on 02/11/2026 01:53 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 CARE		FACILITY NUMBER:	347003007
ADMINISTRATOR/ DIRECTOR:	FLOWERS, RITA C.		FACILITY TYPE:	740
ADDRESS:	8978 MERLOT WAY		TELEPHONE:	(916) 689-5828
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95829
CAPACITY: 5		CENSUS: 5	DATE:	02/11/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Rita Flowers		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 2/11/26, Licensing Program Analyst, LPA, Cynthia Tamayo arrived toarrived unannounced to conduct an annual inspection. Upon arrival,LPA met with care staff Joel Cruz (S2) and Esmalla Ehmije (S3) and explained the purpose of the visit. Administrator, Rita Flower was not present, S2 called S1 and they arrived moments later. An entrance interview was conducted. Sta. Rita's Senior Care is a Residential care elderly 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. There are 5 residents in care. LPA observed here were 2 staff present and four residents were having rice and meat for lunch. Resident 5 (R5) was not present at the facility due to being hospitalized. S1 stated they submitted an incident report (SIR) to the Regional office today. LPA reviewed reporting requirements and the need to be as detailed as possible for reports. S1 will submit an amended/additional SIR and will create a re-appriasal for R5. LPA toured the facility with S3 and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 115.1 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Tamayo observed first aid supplies, there was a fully-charged and up-to-date fire extinguisher, and functioning carbon monoxide/smoke detectors that are tested periodically. 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: 02/11/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2026

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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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: 02/11/2026

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The facility is conducting quarterly emergency drills and ensuing to use alternating exits during simulations. LPA Tamayo observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA observed a locked cabinet for the storage of medication. LPA Tamayo observed locked cabinets for the storage of cleaning solutions and knives.

The exterior of the building was inspected: There were no outbuildings or bodies of water present and the yard was completely fenced in. There was also a sitting area for residents in the backyard.

Staff and resident files were made available for inspection during this visit. LPA reviewed three resident files (R1-R3) and three staff files (S1-S3). Administrator certificate # 7005966740 and it expires 8/30/2026.
SOC341A will be completed for all staff and added to staff files.

LPA compared the LIC 500 with the roster of staff obtained from Guardian to ensure that all staff had the appropriate background clearances to be working with the residents in care. All were in compliance at the time of this inspection. LPA interviewed two staff members and four residents. S1 reported that activities include singing, exercise, and games.

LPA requested the following documents by 2/20/26 by 5:00PM:
LIC 500: Personnel Report
LIC 308: Designation of Administrative Responsibility
LIC 309: (for any LLC or Corp) if applicable
LIC 402: Surety Bond, if applicable
LIC 610E: Emergency Disaster Plan
Copy of current Liability Insurance

Licensee will ensure to pay annual licensing fees by due date. LPA provided guidance via LIC 9102. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. A copy of this report was provided and an exit interview conducted.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/11/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2026

LIC809 (FAS) - (06/04)

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