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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004958
Report Date: 01/17/2025
Date Signed: 01/17/2025 03:24:55 PM

Document Has Been Signed on 01/17/2025 03:24 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: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: 4DATE:
01/17/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Ermelinda SiebenthalTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 1/17/25 Licensing Program Analyst (LPA) Kevin Gould conducted a case management inspection to address reporting of incidents to the department. LPA met with administrator Ermelinda Siebenthal and together discussed the report.

LPA conducted an inspection to obtain additional medical records and any related incident reports for a former resident. LPA obtained hospice records and obtained and incident report dated 9/26/24. LPA had no record or receiving this incident report and it was confirmed by a staff member through fax transmission logs and email history that the incident report dated 9/26/24 regarding fall and injury of former resident was not provided to the department in the time frame required by title 22 regulations.

Per California Code of Regulations, Title 22, the following deficiency is cited.

Exit interview conducted and a copy of this report was left at the home.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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 01/17/2025 03:24 PM - It Cannot Be Edited


Created By: Kevin Gould On 01/17/2025 at 03:06 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: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
87211(a)(1)(B)

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 written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of
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Licensee has agreed to provide a written plan of correction stating an understanding of reporting requirements and specific time frame for reporting. Facility will also provide a step by step plan for reporting incidents to the department.
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admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case... Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met as evidenced by and incident report obtained from the facility dated 9/26/24 was never submitted to the department as confirmed by facility staff which poses a potential health, safety or personal rights risk to residents in care.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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