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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005570
Report Date: 01/28/2025
Date Signed: 01/28/2025 01:47:20 PM

Document Has Been Signed on 01/28/2025 01:47 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 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: 6DATE:
01/28/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Jae KimTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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On 1/28/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with caregiver. LPA and caregiver notified administrator Jae Kim, who arrived to assist.

LPA had completed previous visits, on 1/2/25 and 1/8/25, regarding R1’s unexpected passing.

On 12/1/24, the department received a death notification for R1's passing on 12/1/24.
LPA conducted records reviews and interviews, the department and the county coroner, has concluded that R1 passed due to natural caused related to existing health conditions.

During the review of this incident, the department observed the following deficiencies:

On 12/1/24, S1 responded to R1’s fall. S1 allowed residents to physically move R1 to R1’s bed before emergency services assessed R1. S1 did not follow facility policy or 1st aid training for a resident who had an unwitnessed fall. 87411(a) Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met bases on interviews and records that showed S1 did not demonstrate competency in performing 1st aid to R1. This posed a potential risk to the resident.

During the investigation of this incident it was found that Administrator destroyed R1’s unused medication without recording the medication destruction. An advisory was issued for this deficiency.

R1’s family arrived when notified that R1 had died. The family member observed S1 take a photograph or R1 and send the photo to a staff who had previously worked at the facility and knew R1 well. 87468.2 (a)(1)Additional Personal Rights of Residents in Privately Operated

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CLARA CARE HOME
FACILITY NUMBER: 347005570
VISIT DATE: 01/28/2025
NARRATIVE
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Facilities (a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations… This requirement was not met based on statements that S1 photographed and shared a photo of R1 without consent. This posed a potential risk to R1’s personal rights.

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.



Report reviewed. Copy of report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2025 01:47 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 01/28/2025 at 01:19 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: CLARA CARE HOME
FACILITY NUMBER: 347005570

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
CCR
87411(a)

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Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met bases on interviews and records that showed S1 did not demonstrate
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Licensee will review staff training for competency and submit a list of staff who's competency has been reviewed and topics confirmed by the POC date of 2/28/25
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competency in performing 1st aid to R1. This posed a potential risk to the resident.
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Type B
02/28/2025
Section Cited
CCR87468.2(a)(1)

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Additional Personal Rights of Residents in Privately Operated Facilities (a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations… This
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Licensee will review resident rights with all staff and submit a list of staff who have demonstrated understanding of the rights.
List of training to be submitted by the POC date of 2/28/25.
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requirement was not met based on statements that S1 photographed and shared a photo of R1 without consent. This posed a potential risk to R1’s personal rights
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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:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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