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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002676
Report Date: 12/07/2023
Date Signed: 12/07/2023 11:14:19 AM

Document Has Been Signed on 12/07/2023 11:14 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:WESTSIDE ASSISTED LIVINGFACILITY NUMBER:
455002676
ADMINISTRATOR:SINGH, REEMAFACILITY TYPE:
740
ADDRESS:915 HALLMARK DRTELEPHONE:
(530) 605-4041
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY: 6CENSUS: 6DATE:
12/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Audra EneixTIME COMPLETED:
11:25 AM
NARRATIVE
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During the course of the investigation for complaint 25-AS-20230217110723, the administrator during the time frame February 2023 to May 2023, the resident records were not made available to a Community Care Licensing Investigator. Per Title 22 Regulations, Resident Records 87506(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.

Deficiencies are being cited today. California Code of Regulations (Title 22) is being cited on the attached LIC 809D.
Appeal rights are provided, and a closure interview was conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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 12/07/2023 11:14 AM - It Cannot Be Edited


Created By: Kerry Hiratsuka On 12/07/2023 at 10:37 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: WESTSIDE ASSISTED LIVING
FACILITY NUMBER: 455002676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/29/2023
Section Cited
CCR
87506(d)

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Resident Records. All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.
This requirement was not met as evidenced based by; upon record review and interviews,
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By 12/29/2023, the licensee shall come up with a plan to ensure resident and staff records are available for review by a community care licensing division agent upon request.
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the records for residents were not made available for an investigator, which poses/posed a potential health, safety or personal rights risk to persons 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:Troy Ordonez
LICENSING EVALUATOR NAME:Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
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