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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005570
Report Date: 01/02/2025
Date Signed: 01/09/2025 07:48:02 AM

Document Has Been Signed on 01/09/2025 07:48 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CLARA CARE HOMEFACILITY NUMBER:
347005570
ADMINISTRATOR/
DIRECTOR:		KIM, JAE YOELFACILITY TYPE:
740
ADDRESS:4665 FREEWAY CIRCLETELEPHONE:
(916) 900-4781
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY: 6CENSUS: 4DATE:
01/02/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:50 PM
MET WITH:CaregiverTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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On 1/2/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with caregiver. LPA and caregiver notified administrator Okki Kim, who arrived to assist.

On 12/1/24, the department received a death notification for R1's passing on 12/1/24.
The report stated that R1 awoke in the morning and was at baseline. Declined lunch due to a headache. R1 spoke with family by phone at approximately 2 PM. At approximately 3 PM R1 was checked by staff and R1 reported to staff the "I'm okay". at approximately 4:30 PM a noise was heard and R1 was found, by S1, to have fallen on the way to the bathroom. R1 was found unresponsive 9-1-1 was called, CPR was performed and EMS was unable to revive R1.

LPA received and reviewed records for R1 prior to today's visit.

LPA inspected R1's prior bedroom. R1 ambulated with a walker. The distance from R1's bed to the bathroom is approximately 8 feet. The walker was found near R1 in the bathroom.

Caregiver (s1) who was present when R1 fell is not present today. LPA received caregiver's contact information.

As a result of today’s inspection, no deficiencies were noted.

Report reviewed. Copy of report and appeal rights provided
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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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