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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005474
Report Date: 07/24/2025
Date Signed: 07/24/2025 10:41:10 AM

Document Has Been Signed on 07/24/2025 10:41 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:HEART COURT MANORFACILITY NUMBER:
347005474
ADMINISTRATOR/
DIRECTOR:		NAI SAETEURNFACILITY TYPE:
740
ADDRESS:7230 RUSH RIVER DRIVETELEPHONE:
(916) 476-6214
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 6DATE:
07/24/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Gloria RamirezTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
NARRATIVE
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On 7/24/25 at 8:30am, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management inspection to address concerns of the facility reporting incidents timely and concerns the facility is not following all aspects of an exception for a resident with G-Tube feeding. LPA met with identified administrator Gloria Ramirez.

LPA conducted interviews with S1 and S2 (see confidential names list, LIC 811) dated 7/24/25. Both staff members interviewed identified the steps and process for feeding R1 through their G-Tube. Based of the information provided the department has determined the facility is not in compliance with the exception for R1 as staff members have been feeding R1 without a licensed qualified professional conducting the feedings. Documentation reviewed by LPA for R1 indicated that multiple physician's reports reviewed all indicate that R1 is unable to assist with prescription medications.

Additionally, LPA observed several hospitalizations for R1 related to the feeding tube in May April and July 2025 with no incident reports being provided to the department. The exception for R1 clearly states incident reports related to changes for R1 that require prompt medical attention. LPA also observed that a newly appointed Administrator has been working in that capacity since February 2025 and the department has not received notification of the new appointment and the new administrator has not been approved by the department.

Per the California Code of Regulations, Title 22, The following deficiencies are cited during todays inspection. Exit interview conducted and a copy of this report and appeal rights were left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Kevin Gould
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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 07/24/2025 10:41 AM - It Cannot Be Edited


Created By: Kevin Gould On 07/24/2025 at 10:04 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: HEART COURT MANOR
FACILITY NUMBER: 347005474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2025
Section Cited
CCR
87455(c)(2)

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Acceptance and Retention Limitations: No resident shall be accepted or retained if any of the following apply: The resident requires 24-hour, skilled nursing or intermediate care as specified in Health and Safety Code Sections 1569.72(a) and (a)(1). this requirement is not met as
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The licensee has agreed to submit an updated care plan for R1 which adheres to the stipulations of the exception for R1. facility will also obtain a written statement from R1's physician whether or not they are able to administer own medications including g-tube feedings and insulin injections.
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 evidenced by statements and demonstrations by facility staff that they are proving R1's feedings via G-Tube and not an appropriately skilled professional and documentation reviewed which indicates R1 is unable to manage own medication administration which poses an immediate health, safety and personal rights risk to residents in care.
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Type B
08/01/2025
Section Cited
CCR87211(a)(1)

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Reporting Requirements: A 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,
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Administrator agrees to provide updated incident reports for all of R1's recent hospitalizations and will provide a written plan of correction that the licensee and administrator understand the reporting requirements identified in regulations and provide training to all staff members who may have to submit an incident report.
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 sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by statements and documentation reviewed that R1 was at the hospital related to G-Tube issues in May, April and July 2025 with no incident reports sent to the department 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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Kevin Gould
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2025 10:41 AM - It Cannot Be Edited


Created By: Kevin Gould On 07/24/2025 at 10:13 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: HEART COURT MANOR
FACILITY NUMBER: 347005474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2025
Section Cited
CCR
87211(g)

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Reporting Requirements: The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator... This requirement was not met as evidenced by LPA has received no notification or documentation from the licensee to approve a new
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Facility will provide all required documents to approve a new administrator including and update LIC 200, LIC 500, LIC 501 and current Administrator certificate.
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administrator who has been working in their capacity as an administrator since February 2025 which poses a potential health, safety and 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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Kevin Gould
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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