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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004963
Report Date: 10/02/2026
Date Signed: 10/02/2026 04:42:02 PM

Document Has Been Signed on 10/02/2026 04:42 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MILES MANORFACILITY NUMBER:
347004963
ADMINISTRATOR/
DIRECTOR:		ROSA, KIMBERLYFACILITY TYPE:
740
ADDRESS:4301 WATKINS DRIVETELEPHONE:
(916) 967-9049
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 15CENSUS: 14DATE:
10/02/2026
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Rachel Miles, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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An informal conference was conducted at 2:00 PM on October 2, 2026, with Sacramento North Regional Office. The purpose of this informal conference meeting is to address and discuss concerns regarding the most recent inspections conducted at the care home, including videos obtained by the Department of an incident involving a resident inside the care home. Licensee was told that this Informal conference is a part of the Administrative Action process and that further noncompliance may result in an elevation to a formal noncompliance conference, which could lead to a referral to the Department's legal division for possible revocation of license.

The following Licensing staff were present:
Licensing Program Analyst (LPA) Michael Hood and Licensing Program Manager (LPM) Lauren Crocker

The following facility representatives were present:
Licensee, Rachel Miles, and Administrator, Kim Rosa

The following topics were covered during today's meeting:
· Personal Rights of the residents in care
· Staff competency and expectations
· Purposes of eviction process

** Report continued on 809-C **
Lauren Crocker
Michael Hood
DATE: 10/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2026
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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MILES MANOR
FACILITY NUMBER: 347004963
VISIT DATE: 10/02/2026
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LPA obtained video surveillance footage from a camera located in the common area of the care home and pointed towards the dining room, kitchen area, and front entrance. The footage obtained showed an incident that occurred on February 7, 2026 regarding resident (R1) that contains audio recording of the incident, including conversations between R1 and staff on and off-site. At approximately 3:50 PM, R1 is seen at the front entrance requesting for “air” and to be allowed outside with Administrator standing between R1 and the front entrance. Staff members (S1 and S2) are seen present during the incident. Video footage lasts for approximately a half hour in which R1 is prevented from going outside by Administrator and care staff. Administrator is seen on the phone while interfering with R1's ability to go outside for the entire 30 minutes of footage. Administrator is seen offering R1 PRN medication in response to R1 asking for air and requesting to go outside. Video footage shows Administrator and staff making no attempts to provide any services to de-escalate incident, including providing R1 and ability to go outside, resulting in R1 breaking a chair, throwing water, and R1 requesting law enforcement to be called. Emergency services were called to the facility and R1 was sent to the hospital.

Facility representatives were notified that the Department may increase monitoring at the facility. Technical support was offered to facility representative during meeting and the facility will be referred.

As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are listed on 809-D page.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Michael Hood
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2026 04:42 PM - It Cannot Be Edited


Created By: Michael Hood On 10/02/2026 at 12:33 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: MILES MANOR
FACILITY NUMBER: 347004963

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2026
Section Cited
CCR
87468.2(a)(1)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in (...) communications (...). This requirement is not met as evidenced by:
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Licensee will provide a written statement indicating that audio will be deactivited from all indoor cameras. Licensee will submit statement to LPA by POC due date.
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Based on observation and videos obtained by the Department, staff did not ensure that residents were accorded a reasonable level of personal privacy at the care home by recording audio in common areas, which poses an immediate health, safety, and personal rights risk to the residents in care.
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Type A
10/03/2026
Section Cited
CCR87468.1(a)(6)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time (...). This requirement is not met as evidenced by:
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Licensee will update resident's needs and services plan to accommodate resident's preferences and implement a program to reflect resident's choices and goals that do not violate the resident's personal rights. Licensee will submit completed plan to LPA by POC due date.
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Based on observation and videos obtained by the Department, staff did not ensure that resident had the ability to go outside of the care home when requested, which poses an immediate health, safety, and personal rights risk to the 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.
Lauren Crocker
NAME OF LICENSING PROGRAM MANAGER:
Michael Hood
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2026 04:42 PM - It Cannot Be Edited


Created By: Michael Hood On 10/02/2026 at 12:43 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: MILES MANOR
FACILITY NUMBER: 347004963

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2026
Section Cited
CCR
87468.1(a)(1)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
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Facility will obtain de-escaltion training from an outside source for all staff, including Licensee and Administrator. Licensee will submit proof of training to LPA by POC due date.
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Based on observation and videos obtained by the Department, staff neglected resident's requests to go outside, causing resident to escalate in behaviors, which poses an immediate health, safety, and personal rights risk to the residents in care.
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Type A
10/03/2026
Section Cited
CCR87219(h)(2)

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87219 Planned Activities (h) The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas that are easily accessible to residents, protected from traffic, and have adequate shady areas. This requirement is not met as evidenced by:
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Licensee will update activity plan to factor in accomodating the individualized needs of the residents in care and the implementation of outdoor activities. Licensee will submit a written plan to LPA by POC due date.
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Based on observation and videos obtained by the Department, staff did not ensure access to outdoor space and activities for resident in care, which poses an immediate health, safety, and personal rights risk to the 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.
Lauren Crocker
NAME OF LICENSING PROGRAM MANAGER:
Michael Hood
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2026 04:42 PM - It Cannot Be Edited


Created By: Michael Hood On 10/02/2026 at 12:49 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: MILES MANOR
FACILITY NUMBER: 347004963

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2026
Section Cited
CCR
87405(h)(8)

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87405 Administrator - Qualifications and Duties (h) The administrator shall have the responsibility to:
(8) Have the personal characteristics, physical energy and competence to provide care and supervision (…). This requirement is not met as evidenced by:
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Facility will obtain dementia care training and personal rights training from an outside source for Administrator. Licensee will submit proof of training to LPA by POC due date.
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Based on observation and videos obtained by the Department, Administrator did not exhibit personal characteristics or competence to provide adequate care and supervision to resident in need, which poses an immediate health, safety, and personal rights risk to the 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.
Lauren Crocker
NAME OF LICENSING PROGRAM MANAGER:
Michael Hood
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2026


LIC809 (FAS) - (06/04)
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