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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004505
Report Date: 08/14/2025
Date Signed: 08/14/2025 03:32:54 PM

Document Has Been Signed on 08/14/2025 03:32 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:ALL CARE, LLCFACILITY NUMBER:
347004505
ADMINISTRATOR/
DIRECTOR:		RAY GINFACILITY TYPE:
740
ADDRESS:5901 WITT WAYTELEPHONE:
(916) 714-5170
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 6DATE:
08/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Shiela SeabergTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 8/14/2025, Licensing Program Analysts, Ellen "Triel" Lindstrom and Arvin Villanueva (LPAs) arrived unannounced at this facility to conduct their annual inspection visit. LPA met with staff on duty (S3) and stated the purpose of the visit. The Administrator on record Raymond Gin (S1) was notified and informed LPAs that the Co-Administrator Shiela Seaberg (S2) will assist with the annual because Raymond is currently unavailable. S2 arrived shortly after.

Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 non-ambulatory elderly residents. Facility has a hospice waiver for 2 residents.

Initial Observation: Upon arrival LPAs were greeted by staff on duty (S3). Present during this visit were 6 residents in care with one staff on duty. LPA observed required posters and facility license at the entrance. Room temperature was at 78 degrees Fahrenheit upon arrival.

Physical Inspection:
Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPAs inspected 3 of 5 resident bedrooms. LPAs observed 2 of 3 resident bathrooms. LPAs measured the hot water temperature in the 1 of 3 bathrooms to be at 111 degrees Fahrenheit.
Fire extinguisher was observed in the kitchen area and was last inspected on 5/13/2025. Smoke and carbon monoxide detectors were observed throughout.
{Con't to 809-C}
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2025
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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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: ALL CARE, LLC
FACILITY NUMBER: 347004505
VISIT DATE: 08/14/2025
NARRATIVE
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{Con't from 809}
Medication cabinet was inspected. Kitchen area and pantry were observed. Kitchen refrigerator and freezer were inspected.
Laundry room and garage area were also inspected. The door to the laundry was unlocked during this visit. The laundry room leads to the garage. The door to the garage was observed to be unlocked. The door to the garage can be unlocked from the inside.
Outdoor area was inspected including fence, gates, ramps and emergency walkways.
Record Reviews:
Review of 3 of 3 resident files (R1, R2, R3) was conducted, include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status.
Medication review of 2 residents (R1, R3) include review of physician orders for over-the-counter medications.
Review of 3 staff files (S3, S4, S5) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. No issues were noted.
LPAs also reviewed fire drill/disaster drill records; facility conducts quarterly drills.
LPAs was requested a copy of current Liability Insurance Certificate, LIC500 and LIC308 to be submitted to the Department.

Advisories were provided:
  • Update residents medical assessments. Per resident record review, R3 did not have updated medical assessment available for review.
  • Obtain PRN Authorization Letter from residents' physician. 3 of 3 residents did not have PRN Authorization on file to determine whether residents are able to communicate their needs for PRN medication.
  • Advisory was provided to develop Infection Control Plan and submit to the Department.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
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: ALL CARE, LLC
FACILITY NUMBER: 347004505
VISIT DATE: 08/14/2025
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Deficiencies were observed:
  • Medication (M1) belonging to R3 was observed inside the bathroom cabinet in bedroom #4. This medication was placed in an unlocked cabinet accessible to residents in care. Per record review, R3 is unable to manage own medication.
  • Medication cabinet was observed to be unlocked and accessible to residents upon arrival.
  • Garage houses a refrigerator. Inside this refrigerator, LPAs observed medication (M2) belonging to R1 inside the refrigerator.
  • Also inside the garage, LPAs observed paint containers on the floor accessible to residents in care.
  • Inside the laundry room, LPAs observed a laundry detergent inside an unlocked cabinet.
  • One of the exit gates did not have a self-latching lock. Per review of the facility sketch, this gate is an emergency exit.
  • Record reviews and interviews revealed that facility do not document PRN medication administration.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited. Exit interview was conducted with S1. A copy of the report was provided upon exit.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 03:32 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 08/14/2025 at 02:55 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: ALL CARE, LLC
FACILITY NUMBER: 347004505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Laundry detergent was accessible in the laundry room and paint containers were accessible in the garage area which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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Per discussion, administrator will provide training to staff. Proof of training will be submitted to the Department by POC due date.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Medication closet was observed to be unlocked during this visit. Additionally, medications were observed in resident bathroom and inside the garage refrigerator and are accessible to residents. These poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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Per discussion, administrator will obtain a locked box for the medications that require refrigerator.
Per discussioin, administrator will retrain staff regarding the regulation cited above. Proof of training will be submitted to the Department by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 03:32 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 08/14/2025 at 02:55 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: ALL CARE, LLC
FACILITY NUMBER: 347004505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. 1 of 2 exit gates was observed to be missting a self-latching lock which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2025
Plan of Correction
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Per discussion, Administrator will submit a photo of the repaired gate to the Department by POC due date.
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. Facility do not document PRN medication administration which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2025
Plan of Correction
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Per discussion, administrator will submit a letter of acknowledgement of the cited regulation and will state they will start documenting PRN medication administration. Submit letter by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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