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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701159
Report Date: 08/31/2026
Date Signed: 08/31/2026 04:46:02 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/31/2026 04:46 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:BEATRICE SENIOR CAREFACILITY NUMBER:
342701159
ADMINISTRATOR/
DIRECTOR:		CLARK, TIMOTHYFACILITY TYPE:
740
ADDRESS:8901 MELODIC CTTELEPHONE:
(916) 270-3961
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
08/31/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Beatrice Clark TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 8/31/2026, at approximately 9:00 AM, Licensing Program Analysts (LPAs) Reza Jamaly and Pang Lee arrived unannounced at the facility to conduct the required one-year inspection. LPAs met with the staff on duty and explained the purpose of the visit. The Licensee, Beatrice Clark, was notified and arrived at the facility shortly thereafter.

Upon arrival, LPAs observed an individual (I) setting on a couch in the living room. Staff 1 (S1) identified I as a friend. LPA Pang checked Guardian and determined that I was associated with Beatrice Home Care.
LPAs Jamaly and Pang conducted a physical plant inspection of the facility, including, but not limited to, the common areas, kitchen, dining area, hallways, four residents’ bedrooms, resident bathrooms, garage, and exterior courtyards, to assess compliance with applicable Title 22 regulations.

LPAs inspected the kitchen and observed four cleaning products, including Palmolive, Dawn, Clorox, and Windex, stored in an unlocked cabinet accessible to residents. Photographs were taken. A deficiency was cited on LIC 809-D.
Sharp knives were observed stored in a locked kitchen cabinet and were inaccessible to residents.
LPAs inspected the refrigerator and freezer located in the kitchen and observed three containers of leftover food that were not labeled or dated, including cooked lentils, scrambled eggs, and macaroni and tuna. A can of Pepsi was also observed opened. Photographs were taken. A deficiency was cited on LIC 809-D.

The facility was observed to have a sufficient supply of at least seven days of nonperishable food and two days of perishable food.

Stephen Richardson
Reza Jamaly
DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
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)
Page: 2 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159
VISIT DATE: 08/31/2026
NARRATIVE
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Page 2.
LPAs inspected four residents’ bedrooms. An odor of incontinence was detected in Room 3. LPAs observed three partially filled urinal containers hanging from the resident’s walker in Room 3.
Based on LPAs interview it was learned that urinal container was not emptied today. A deficiency was cited on LIC 809-D.
During hallway inspection, LPAs observed a container full of used glucose test strips. Per licensee, resident checked their own blood glucose and placed the used test strips in it. Deficiency cited on LIC 809-D

Resident bathrooms were observed to be clean. Grab bars and nonslip mats were observed to be secure and in good condition.


The hot water temperature at one resident bathroom sink was measured at 103.4°F, which is below the required range of 105°F to 120°F. A deficiency was cited on LIC 809-D. The facility temperature was measured at 71°F in the living room. No bodies of water were observed on the premises.
Smoke detectors and carbon monoxide detectors were observed throughout the facility. Fire extinguishers located in the living room and hallway were observed and had a last service date of 3/11/2026.
Cleaning supplies and other toxic substances were observed stored in the garage. The garage door was locked, making the substances inaccessible to residents. The Licensee unlocked the garage door to allow LPAs to conduct the inspection.
Medications were observed stored in a locked cabinet located in a hallway and were inaccessible to residents.
LPAs requested and inspected the medications for three residents. No Medication Administration Records (MARs) or Centrally Stored Medication and Destruction Records (CSMDR) were available for review at the time of the inspection.
The Licensee stated, “I am administering residents’ medications regularly, and I am documenting on the MAR, but I cannot locate them right now.”Due to the absence of the MARs, LPAs were unable to verify whether the residents’ medications were being administered as prescribed. Deficiencies were cited on LIC 809-D. The first aid kit was inspected and contained the required supplies.
LPAs inspected the facility yard and observed multiple sections of fencing with loose containing nails. Photographs were taken. The Licensee stated that the fence had recently been repaired and that the remaining old fencing would be removed and discarded.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Reza Jamaly
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2026
LIC809 (FAS) - (06/04)
Page: 3 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159
VISIT DATE: 08/31/2026
NARRATIVE
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LPAs also observed bulky items, including an old mattress, chair, desk, and Hoyer left, on the right side of the facility that obstructed access to emergency exit door. An old washing machine was also observed outside the facility in front of the garage, obstructing an exit door. Photographs were taken. A deficiency was cited on LIC 809-D.

LPAs requested resident records and reviewed four out of four resident files. One of the four resident files did not have a current Care Plan.
LPAs requested the administrator file The Licensee was unable to locate the staff file and stated, “I cannot find it.” A deficiency was cited on LIC 809-D.
The following additional documents were requested from the facility and are to be provided to the LPA Jamaly by email no later than 5:00 PM on the requested due date of 9/7/2026.

(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate   
(4) LIC 610 Current Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) LIC 500 Current Personnel Report
(7) LIC 309 Administrator Organization

Based on the observations made during the annual inspection, the facility was found to be out of compliance with applicable Title 22 regulations. The identified deficiencies are documented on the LIC 809-D pages.
An exit interview was conducted with S1. LPAs reviewed the inspection findings with the Licensee and provided copies of the LIC 809 report, LIC 809-D pages, and Appeals Rights.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Reza Jamaly
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2026
LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 08/31/2026 04:46 PM - It Cannot Be Edited


Created By: Reza Jamaly On 08/31/2026 at 01:50 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: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2026
Section Cited
CCR
87355(e)(3)

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87355(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(3) Request a transfer of a criminal record clearance..
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Administrator/Licensee will ensure all individualls who come to facility are finger printed and associated.
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Based on observation and interview there was an individual (I) at the facility who was not associated to the facility; however, individual was fingerprint cleared.
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Type B
09/15/2026
Section Cited
CCR87463

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87463 (a) The pre-admission appraisal.., shall be updated in writing as frequently as necessary or once every 12 months.
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Administor/Licensee will create Care Plan for R1 file and provide a copy of the Care Plan to LPA Reza Jamaly by due date
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Based on the observation and interview with Licensee 1 out of 4 residents did not have a completed LIC 625 needs and service/care plan in place in their files which poses totential health and safety risks 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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Reza Jamaly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2026


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 08/31/2026 04:46 PM - It Cannot Be Edited


Created By: Reza Jamaly On 08/31/2026 at 02:17 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: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2026
Section Cited
CCR
87303(e)(2)

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Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water
used by residents to attain a temperature of not less than 105-degree F (41 degree C) and not more than 120-degree F (49 degree C)
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Administrator/ Licensee will ensure hot water tempreture is adusted as requeired by Title 22 regulation.
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Based on observation the hot water was measured at 103.4 *F in the resident main bathroom sink which posess an immediate health and safety risks to resents in care
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Type A
09/07/2026
Section Cited
CCR87465(a)(6)

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(a) A plan for incidental medical and dental care shall be developed by each facility..
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
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The Licensee will maintain and accurately fill MAR or CSMDR on each residents file and provide completed copy of all 4 resident's MAR or CSMDR to LPA Jamaly by due date.
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Based on records review and interview with Administrator Beatrice’s statement she does not know where the residents CSMDR records are and cannot locate them which posess an immediate health and safety risks to resents 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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Reza Jamaly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2026


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 08/31/2026 04:46 PM - It Cannot Be Edited


Created By: Reza Jamaly On 08/31/2026 at 02:32 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: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2026
Section Cited
CCR
87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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Administrator/Licensee will remove all the wooden fence containing nails and send a picture of the yeard emtied from the those fences.
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Based on observations, the facility was not maintained in good repair or in a clean condition. LPAs also observed long wooden fence boards with exposed, protruding nails on the ground in the rear courtyard. Additionally, the facility’s refrigerator was observed to be unclean.
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Type A
09/07/2026
Section Cited
CCR87555(b)(8)

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87555(b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
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Administrator/ Licensee throw out the unlabeled leftover foods.
Administrator/ Licenseen will ensure foods are stored properly dated and labeled and will provide training to direct care staff to keep food in refrigerator and freezer properly.
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Based on observation, three containers of leftover food that were not labeled or dated, including cooked lentils, scrambled eggs, and macaroni and tuna. A can of Pepsi was also observed opened.
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Reza Jamaly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2026


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 08/31/2026 04:46 PM - It Cannot Be Edited


Created By: Reza Jamaly On 08/31/2026 at 02:54 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: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2026
Section Cited
CCR
87309(a)

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87309(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects...
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Licensee/administor immediately removed the cleaning solutions.
Licensee will provide training to staff to keep chemicals locked and inaccessible to residents. Provide proof of traning completed including training title, date, trainee's name and signature by due date.
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Based on observation, four cleaning products, including Palmolive, Dawn, Clorox, and Windex, stored in an unlocked cabinet accessible to residents, which poses immediate health and saftey risks to residents in care.
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Type A
09/07/2026
Section Cited
CCR87303

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(f) All waste shall be located..Syringes and needles are disposed of..concerning bloodborne pathogens.

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Licensee throw out the used glucose stripts.
Licensee will provide training to direct care staff to maintain facility clean and provide proof of traning completed including training title, date, trainee's name and signature by due date.
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Based on observations and statements, it was learned that a resident checked their own blood glucose and placed the used test strips in a clear container and the container was full of used glucose stripes on the hallway counter, where they were accessible to residents in care which which poses an immediate health and saftey risks 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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Reza Jamaly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2026


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 08/31/2026 04:46 PM - It Cannot Be Edited


Created By: Reza Jamaly On 08/31/2026 at 03:07 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: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2026
Section Cited
CCR
87625(b)(3)

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 87625 Managed Incontenece
(b) The licensee shall be responsible for the following:
(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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Administor/ Lencess instructed direct staff to empty out the urinal tube.
Administrator/Licensee will provide training to staff on keeping residents and facility clean and provide proof of traning completed including training title, date, trainee's name and signature by due date.

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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Reza Jamaly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2026


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 08/31/2026 04:46 PM - It Cannot Be Edited


Created By: Reza Jamaly On 08/31/2026 at 03:13 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: BEATRICE SENIOR CARE
FACILITY NUMBER: 342701159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2026
Section Cited
CCR
87307

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(d)The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This was not met as evidence by:
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Administrator/Licensee will remove all the items obstructing the exit door. Once removed the licensee will send a picture of the emergency exit being cleared.

Administrator/Licensee will provide training to staff to keep the passage way and exit doors free of obstructions and provide proof of training completed.
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LPAs Pang and Jamaly observed bulky items, including an old mattress, chair, desk, and sports equipment, on the right side of the facility that obstructed access to emergency exit doors. An old washing machine was also observed outside the facility in front of the garage, obstructing an exit door.
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Type B
09/15/2026
Section Cited
CCR87412

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87412 (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This is not met as evidence by:
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Licensee/Administrator will email the Administrator and S1 required staff file documents to LPA Jamaly by due date by due date.
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Based on observations and interviews with the Licensee she couldn’t located the Administrator Timothy Clark and care staff files which poses potential health and safety risks 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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Reza Jamaly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2026


LIC809 (FAS) - (06/04)
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