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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701667
Report Date: 10/12/2026
Date Signed: 10/12/2026 04:17:17 PM

Document Has Been Signed on 10/12/2026 04:17 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:SPANISH VINES ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
342701667
ADMINISTRATOR/
DIRECTOR:		MORENO-FIGUEROA, ARLENEFACILITY TYPE:
740
ADDRESS:7548 Greenhaven DRTELEPHONE:
(916) 427-8887
CITY:SacramentoSTATE: CAZIP CODE:
95831
CAPACITY: 105CENSUS: 63DATE:
10/12/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Augustin SamaniegoTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On October 12, 2026, at 9:15 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived unannounced at the facility to conduct a case management inspection. LPA Martinez met with Augustin Samaniego and explained the purpose of today’s visit.

The purpose of the visit today, is in response to 87463 (a) Reappraisals deficiency. It was learned that reappraisal were not complete and did document bowel and/or bladder incontinence care needs for twenty-two residents. LPA Martinez requested bowel and/or bladder incontinence care plans, however, LPA Martinez was not provided bowel and/or bladder incontinence care plans because they have not been completed. Facility staff is currently working on completing reappraisals and bowel and/or bladder incontinence care plans.

LPA Martinez conducted interviews with facility Medication technicians and care staff, and learned that their are twenty-two residents that require some form bowel and/or bladder incontinence care. Facility care staff reported that residents briefs are changed every two hours.

Additionally, five out of twenty-two residents did not have a LIC 602 medical assessment for residential care facilities for the elderly (LIC 602). Eight of twenty-two LIC602's indicated that residents were able to care for their own toileting needs. However, the eight residents requires assistance with bowel and/or bladder incontinence care. Reappraisals are not complete or accurate. As a result of this visit, the following deficiency was cited 87463 (a) Reappraisals, per Title 22 Regulations. The deficiencies can be found on 809-D Page.

An exit interview was conducted, and a copy of this report was provided to the facility.

Arielle Pascua
Avelina Martinez
DATE: 10/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2026
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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Document Has Been Signed on 10/12/2026 04:17 PM - It Cannot Be Edited


Created By: Avelina Martinez On 10/12/2026 at 03:16 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: SPANISH VINES ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 342701667

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2026
Section Cited
CCR
87463(a)

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87463 (a) Reappraisals: Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition. This requirement was not met as evidence by: Based on observation, file review, and
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Facility staff is currently working on completing reappraisals, and agrees to review the twenty residents that require bowel and/or bladder incontinence care and update their appraisals and LIC 602's by November 11/02/2026.
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interviews, the Licensee did not ensure residents were care plans were being updated and reflect bowel and/or bladder incontinence care needs. This posed a potential health and safety risk to residents in care.
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LPA Martinez will complete POC review by facility visit. Facility staff will inform LPA Martinez of POC status prior to 10/26/2026 by 5:00 PM.

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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.
Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2026


LIC809 (FAS) - (06/04)
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