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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000702
Report Date: 10/05/2026
Date Signed: 10/05/2026 03:14:36 PM

Document Has Been Signed on 10/05/2026 03:14 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:INDOCARE HOUSE 1FACILITY NUMBER:
347000702
ADMINISTRATOR/
DIRECTOR:		LOMENDEHE, PAULFACILITY TYPE:
740
ADDRESS:8278 NEWFIELD CIRCLETELEPHONE:
(916) 682-5461
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: DATE:
10/05/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:43 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On October 5, 2026, Licensing Program Analysts Arvin Villanueva (LPA), arrived unannounced at this facility to conduct the annual inspection visit. LPA met initially met with staff on duty, Shirley Suak (S1) and stated the purpose of the visit. The administrator, Paul Lomendehe (AD), was notified and was not able to come to the facility.

Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents; up to 6 may be non-ambulatory. Facility does not have clearance for bedridden, delayed egress, and secured/locked perimeter. Facility has a hospice waiver for 2 residents at this time.

Upon arrival: LPA observed the room temperature to be at 74 degrees Fahrenheit. Five of the residents were present during this visit, with three staff on duty. LPA observed a camera at the front of the house and in the kitchen/dining area.

Physical Inspection: Areas that were inspected include, but are not limited to, the resident bedrooms, bathrooms, kitchen area, dining room, other common areas and outdoor areas.

LPA and staff inspected 4 of 4 resident bedrooms, one staff room and 2 resident bathrooms. Hot water temperature was measured in the hallway bathroom, and it was 105.2 degrees Fahrenheit. Per staff on duty, the staff room is locked at all times. Each of the residents’ bedrooms have their own exit doors to the outside.

In the kitchen area, LPA observed at least 7-day nonperishable and 2-day perishable food supplies. Knives/sharps and cleaning solutions were locked. Fire extinguishers observed and last serviced on January 30, 2025. Per interview, the person that serviced the fire extinguisher punched the wrong year. Advised facility to submit the receipt. Smoke and carbon monoxide detectors were observed throughout. Medication cabinet was observed to be locked and not accessible.

The laundry detergents were locked in a cabinet in the garage area. Also in the garage, additional refrigerators and freezers were observed. Some food items were observed to be stored on the garage floor, approximately three (3) feet away from the cleaning chemicals that were also stored on the garage floor. Generator was observed in the garage. Advisory provided to obtain thermometers for the garage refrigerator and freezer to ensure regulatory temperature is maintained. Per staff, residents do not have access to the garage, and it remains locked at all times.

{1}

Stephen Richardson
Arvin Villanueva
DATE: 10/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2026
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: INDOCARE HOUSE 1
FACILITY NUMBER: 347000702
VISIT DATE: 10/05/2026
NARRATIVE
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The outdoor area was inspected, and the fences and gate were observed to be in good repair. No bodies of water were observed. The LPA noted a shaded area with appropriate outdoor furniture available for resident use. Storage shed was observed to be locked. An advisory was provided, reminding the facility to ensure all staff are familiar with the location and operation of utility shut-off valves in case of emergency.

Record Reviews: Documents that were reviewed include, but not limited to, resident files, staff files, and other pertinent facility records.

Review of 3 of 6 resident files (R1, R2 and R2) was conducted, including but not limited to, review of Admission Agreement, Physician Reports, and Ambulatory Status. Both R1 and R2 have one or more restricted health conditions - foley catheter, injection, oxygen, and intermittent positive pressure breathing machine. Per staff interviews and record reviews, facility does not have current restricted health condition care plan for these restricted health conditions at this time. R2’s Medical Assessment (LIC602A) was incomplete – page 7 needs to be completed; Needs and Services Care Plan (LIC625) is missing R2’s signature.

LPA did not review resident medications and first at kit during this visit but may be reviewed on the next visit.

Review of 4 (AD, S1, S2, S3) staff files included but not limited to background clearance, first aid/CPR certification, and training records. Per review, S1 and S2 do not have their Health Screen in their files. S2 does not have a current First Aid certificate. There was no staff training related to the specific restricted health conditions – foley catheter, injection, oxygen, and intermittent positive pressure breathing machine.

Advisory was provided to conduct other types of disaster drills as required, such as earthquakes and flooding. Advisory was provided to administrator to ensure they review their infection control plan and emergency disaster procedure plan at least annually and document each review.

Interviews: 2 staff members were interviewed.

Documents Requested: LPA requested a copy of updated Liability Insurance, Personnel Records (LIC500), and Designation of Facility Responsibility LIC308.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 and Health and Safety Code deficiencies were cited. Advisories were provided.

Plan of Corrections (POC) and appeal rights were discussed during exit interview with S1. A copy of the report and appeal rights process were provided.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2026
LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 10/05/2026 03:14 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 10/05/2026 at 01:58 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: INDOCARE HOUSE 1
FACILITY NUMBER: 347000702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above: staff (S1) did not have their health screen on file; staff (S2) did not have current health screen completed - which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2026
Plan of Correction
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Per discussion, the licensee agreed to submit to the Dept. a written acknowledgement of understanding of the regulation cited above by 10/6/2026.
Per discussion, licensee will submit to the Dept. proof of current health screen for S2 by 10/12/2026.

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:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2026 03:14 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 10/05/2026 at 01:58 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: INDOCARE HOUSE 1
FACILITY NUMBER: 347000702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above: staff (S2) did not have their first aid training completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2026
Plan of Correction
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Per discussion, the licensee will submit proof of first aid certificate to the Dept. by 10/12/2026.
Type B
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation], the licensee did not comply with the section cited above - food items were found stored on the garage floor along with cleaning chemicals which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2026
Plan of Correction
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Per discussion, licensee agreed to store all food items in a separate storage area separate from the chemical storage. Licensee will submit to the Dept a written acknowledgment of understanding of the regulation cited above by 10/12/2026.
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:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2026 03:14 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 10/05/2026 at 02:14 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: INDOCARE HOUSE 1
FACILITY NUMBER: 347000702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87611(b)
The licensee shall complete and maintain a current, written record of care for each resident…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record reviews, the licensee did not comply with the section cited above - at least two residents in care have one or more restricted health condition and licensee did not have restricted health condition care plan in place for each of the conditions. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2026
Plan of Correction
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Per discussion, the licensee will submit to the Department a letter of understanding regarding the requirements for restricted health conditions by 10/6/2026.
Per discussion, the licensee will complete a restricted health condition care plan for each resident’s applicable restricted health condition and submit these care plans to the Dept by 10/12/2026.
Type A
Section Cited
CCR
87613(a)(2)
Ensure that facility staff who will participate in meeting the resident’s specialized care needs complete training provided by a licensed professional sufficient to meet those needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above - there were no evidence of staff training specific to the resident's restricted health conditions. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2026
Plan of Correction
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Per discussion, the licensee will submit to the Dept a letter of understanding related to the requirements of restricted health conditions by 10/6/2026.
Per discussion, the licensee will provide staff training for each of the restricted health conditions for which they are currently providing care. Such training must be provided by a skilled professional. Submit proof of training by 10/12/2026.
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:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2026


LIC809 (FAS) - (06/04)
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