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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701338
Report Date: 09/01/2026
Date Signed: 09/01/2026 12:24:50 PM

Document Has Been Signed on 09/01/2026 12:24 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:KEVINBERG CARE HOMEFACILITY NUMBER:
342701338
ADMINISTRATOR/
DIRECTOR:		PARAMO, FERNANDO PAZFACILITY TYPE:
740
ADDRESS:8351 LANCRAFT DR.TELEPHONE:
(916) 382-9472
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 6CENSUS: 4DATE:
09/01/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:07 AM
MET WITH:Fernando Paz MaramoTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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A Non-Compliance Conference (NCC) was conducted today on September 01, 2026, at Regional Office with the Sacramento South Regional Office. Present at today's meeting include the following: Regional Manager Stephenie Doub, Licensing Program Manager Stephen Richardson, and Licensing Program Analyst Pang Lee. Facility Representatives: Licensee/Administrator Fernando Paz Maramo and Regional Ombudsman Representative Sofia Diaz Terrazas.

The Non-Compliance Conference process was explained during this meeting; also, to include the administrative process.

In the last year, the facility has been cited a total of seven times. The facility received two A citations and five B citations. The citations consist of the following: care and supervision, basic services, reappraisal- change in condition, eviction and reporting requirements.

Issues Discussed During the Noncompliance Conference:

· Complaint No. 27-AS-20260428150655 regarding lack of care and supervision.

· Reporting requirements.

· Facility policies and procedures regarding resident assessments, monitoring, and changes in condition.

· Eviction requirements and procedures.

CONTINUED LIC 809-C

Arielle Pascua
Pang Lee
DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2026
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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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: KEVINBERG CARE HOME
FACILITY NUMBER: 342701338
VISIT DATE: 09/01/2026
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· Residents’ Needs and Services Plans.

· Procedures to follow when a resident experiences a change in condition and the facility can no longer meet the resident’s needs, including:

o Meeting with the resident and the resident’s responsible person.

o Issuing an appropriate eviction notice in accordance with applicable requirements.

o Reassessing the resident’s needs and determining whether the facility can continue to provide the necessary care and supervision.

· The facility’s resident admission process, including:

o Completing a pre-admission appraisal.

o Reviewing the prospective resident’s hospital and medical records.

o Meeting with the prospective resident and family or responsible person to obtain relevant information.

o Maintaining ongoing communication with the resident’s family or responsible person.

o Documenting all communications with the resident’s responsible person and healthcare providers.

o Understanding the purpose of and differences between the resident appraisal and the Needs and Services Plan.

CONTINUED LIC-C

NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KEVINBERG CARE HOME
FACILITY NUMBER: 342701338
VISIT DATE: 09/01/2026
NARRATIVE
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· Additional staff training regarding:

o Eviction procedures.

o Changes in residents’ conditions.

o Wound care, including the identification of Stage 1 and Stage 2 pressure injuries.

The facility has stated they will do the following to achieve continued and substantial compliance:


· Complete Technical Support Program (TSP) services
· Complete additional training on eviction requirements and procedures through an approved vendor with CCLD.
· The facility will report incident reports to the department via fax number 916-263-4744 or CCLASCPSacramentoRo@dss.ca.gov.
· Complete additional training on wound care through an approved vendor with CCLD.
· Develop and submit a written plan describing (Due by September 15, 2026, end of day 5:00 PM):

- How residents will be assessed and monitored for skin conditions.

- How frequently residents’ skin will be checked.

- How skin assessments and observations will be documented.

- The actions staff will take when a wound, skin breakdown, or other irregularity is identified.

In addition, at this meeting the Licensee and facility management were advised future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and further potential administrative action.

CONTINUED LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KEVINBERG CARE HOME
FACILITY NUMBER: 342701338
VISIT DATE: 09/01/2026
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Community Care Licensing Department (CCLD) will do the following:
· Increase monitoring to quarterly visits for 2 years or until concerns are resolved.
· Technical Support Program (TSP). A referral was completed by CCLD.
· Reduce hospice waivers from six to two
· LPA Lee will provide Licensee Maramo the Non-Emergency PIN ASC 24-05 by September 03, 2026, end of day.
· LPA Lee will provide Licensee Maramo CCLD approved vendor information by September 03, 2026, end of day.


Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited at this visit. An exit interview was conducted with Administrator Maramo and a copy of this report was provided at the end of the meeting.
NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2026
LIC809 (FAS) - (06/04)
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