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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701667
Report Date: 09/11/2026
Date Signed: 09/17/2026 10:55:08 AM

Document Has Been Signed on 09/17/2026 10:55 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 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:
958315610
CAPACITY: 105CENSUS: 63DATE:
09/11/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Kaitlynn EaglesonTIME VISIT/
INSPECTION COMPLETED:
03:47 PM
NARRATIVE
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On September 11, 2026, at 1:00 PM, Licensing Program Analyst (LPA) Avelina Martinez arrived unannounced at the facility to conduct a case management inspection. LPA Martinez met with Kaitlynn Eagleson and explained the purpose of today’s visit.

The purpose of the visit today, is in response to follow up on Administrator qualification and duties, and certification requirements, and inspection Authority.

During today's visit, LPA Martinez requested to review facility records. LPA Martinez was not provided the records due to facility staff not having access. In addition, LPA Martinez conducted a phone call to North Star Management Group-Regional Manager during today visit. However, the North Star Management Group-Regional Manager was not available. LPA Martinez left a voicemail and requested a return phone call. LPA Martinez also, conducted a phone call with the interim facility administrator during today's visit. However, the interim facility administrator was not able to attend today's facility visit or provide records.

LPA Martinez also conducted an interview with the Marketing Director, and they do not have access to facility files. LPA Martinez conducted an interview with the Resident Care Coordinator, and they reported they have limited access to facility records, and LPA Martinez was not able to obtain facility records.

Continued...

Arielle Pascua
Avelina Martinez
DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2026
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: SPANISH VINES ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 342701667
VISIT DATE: 09/11/2026
NARRATIVE
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For Administrator changes, the Regional Office requests the following documentation to be submitted by September 14, 2026, by 5:00 PM

· A letter from the licensee and/or Board appointing the individual as the Administrator


· LIC 308 Designation of Responsibility
· Copy of current Administrator Certificate
· LIC 200 signed by the licensee or designee
· LIC 500 to indicate the days/hours the administrator is in the facility
· LIC 501 Personnel Record-(And any documentation that meets the education and/or experience requirements. 87405 (f) Administrator - Qualifications and Duties

As a result of this visit, the following deficiencies were cited 87405 (a) Administrator - Qualifications and Duties) and 87755 (c) Inspection Authority of the Licensing Agency, per Title 22 Regulations. The deficiencies can be found on 809-D Page.

An exit interview was conducted, and a copy of this 809 report, 809 D-Page, and appeals rights were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2026 10:55 AM - It Cannot Be Edited


Created By: Avelina Martinez On 09/11/2026 at 02:34 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: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2026
Section Cited
CCR
87405(a)

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87405(a): All facilities shall have a qualified and currently certified admin...When the admin is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified
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Facility staff agrees to update LIC 308 designation of responsibility and designate a substitute Administrator that has qualifications adequate to be responsible and accountable for management and administration of the facility by POC date 09/25/2026.
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in this section.This requirement was not met as evidence by: based on observation/interviews, on 09/11/26 the Licensee did not ensure that a substitute admin had ability to access records and manage the facility. This posed a potential health/safety risk to residents in care.
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Facility staff agrees to email LPA Martinez LIC 308 and appointed substitute administrator documentation by POC date 09/25/2026 by 5:00 PM
Type B
09/25/2026
Section Cited
CCR87755(c)

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87755(c): The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. This requirement was not met as evidence by: based on observation and records request,
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Facility staff agrees to implement a plan to make facility records available to CCLD during normal business hours by POC date: 09/25/26. Facility staff agrees to email plan to LPA Martinez by 09/25/26 by 5:00 PM.
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the Licensee did not ensure that facility records were made available to inspect and be reviewed on the 09/11/26 inspection visit. This posed a potential health and safety risk 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.
Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


LIC809 (FAS) - (06/04)
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