<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004958
Report Date: 10/30/2024
Date Signed: 10/30/2024 11:51:43 AM

Document Has Been Signed on 10/30/2024 11:51 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SIEBENTHAL CARE HOMEFACILITY NUMBER:
347004958
ADMINISTRATOR/
DIRECTOR:		SIEBENTHAL, ERMELINDAFACILITY TYPE:
740
ADDRESS:7948 HUNTS RUN WAYTELEPHONE:
(916) 689-3595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 5DATE:
10/30/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Emerlinda SiebenthalTIME VISIT/
INSPECTION COMPLETED:
12:15 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 10/30/24 Licensing Program Analysts (LPAs) Kevin Gould and Holly Williams conducted an unannounced POC inspection to ensure previously cited deficiencies have been corrected.

LPAs met with the licensee to review plans of correction.

LPA observed the facility staff is in process of obtaining criminal records clearances and health screening/TB tests as LPAs observed scheduled appointments for health screaming and actions taken to complete criminal record clearances.

LPA Gould has not received written plans of correction for health screening and criminal record clearances, an extension was granted to the licensee to complete the written plans of correction by 10/31/24.

LPA has not received an LIC 200 and supporting documents to appoint a new administrator who is pending certification so LPA can expedite the administrator approval and ensure there is a certified administrator for the facility.

An immediate civil penalty was issued for failure to correct the plan of correction.

Exit interview conducted and a copy of this report and appeal rights are left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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 1