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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001382
Report Date: 04/16/2024
Date Signed: 04/16/2024 03:05:52 PM


Document Has Been Signed on 04/16/2024 03:05 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:ROSES AND IVY ELDER CAREFACILITY NUMBER:
045001382
ADMINISTRATOR:PERRY, BRIANFACILITY TYPE:
740
ADDRESS:853 MANZANITA COURTTELEPHONE:
(530) 894-7836
CITY:CHICOSTATE: CAZIP CODE:
95926
CAPACITY:20CENSUS: 13DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Cindy Denney TIME COMPLETED:
03:15 PM
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On 04/16/2024 Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Cindy Denny, and explained the purpose of the visit.

LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. LPA observed the facility to be clean, in good repair and odor-free. In the areas toured no immediate health, safety, or personal rights violations were observed.

Areas toured include but are not limited to: common areas, resident bedrooms, backyard, sheds, and common restrooms. LPA observed each bathroom and shower room to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids. LPA observed each resident bedroom to have the required furnishings, working lights and windows with screens. LPA observed activity calendar to be in plain view for the residents and a plethora of activities for the residents to engage. LPA observed the kitchen to be clean and well organized with postings for residents with special diets in plain view for the staff to observe. Facility has a 2-day perishable and a 7-day non-perishable amount of food. Hot water temperature was measured at 113 F.

LPA observed four (4) fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed the first aid kit to be complete and ready for emergency use. LPA observed a completed emergency disaster plan with required emergency disaster drills conducted and documented. LPA observed the chemicals and medications to be locked and inaccessible to residents.

LPA reviewed a total of six (6) residents' files and four (4) staff files which contained all of the required documentation.

Several topics were discussed.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
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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