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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002620
Report Date: 02/21/2024
Date Signed: 02/21/2024 02:57:46 PM


Document Has Been Signed on 02/21/2024 02:57 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:INN AT THE TERRACES, THEFACILITY NUMBER:
045002620
ADMINISTRATOR:KEENE, CLIFFFACILITY TYPE:
740
ADDRESS:2950 SIERRA SUNRISE TERRACETELEPHONE:
(530) 894-5429
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:99CENSUS: 80DATE:
02/21/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Administrator- Cliff Keene TIME COMPLETED:
03:15 PM
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On 2/21/2024 Licensing Program Analyst (LPA) Jaynae Boyles arrived at the facility unannounced to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 11/03/2023-11/03/2025. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review upon request. LPA met with the Administrator, Cliff Keene.
During today's visit, LPA reviewed the following stipulations of the order:
1. Staff shall be sufficient in number, qualifications and competency and shall provide additional back up staff to provide the services necessary to meet residents’ needs
· During inspection, LPA observed LIC 500 and staff schedule and found staff to be sufficient in number. LPA observed training that was conducted from November to February which was found to be sufficient.
2. Facility shall inform all current and prospective residents and/or responsible parties of the facility’s probationary license by providing to the residents/residents’ responsible party a copy of the stipulation.
· LPA observed notification of the stipulation within the resident file that they or their responsible party was notified of the stipulation. LPA observed notification of the stipulation for new residents in the admissions agreement.
3. Facility shall ensure that each resident is able to receive three nutritionally well-balanced meals which within 30 days of the effective date of the stipulation shall incorporate the policy of maintaining a Daily Resident Meal Check List into the plan of operations.
· LPA observed Daily Resident Meal Check list for the last 30 days which is sufficient in ensuring that residents are receiving meals and the staff are checking to ensure that residents are receiving meals if they choose. The Daily Resident Meal Check List is in the plan of operations, as required by the stipulation.
4. Facility shall submit a written summary of hiring and training practices, including job descriptions to the licensing agency.
· LPA observed that the administrator is working to complete this task.
5. Facility staff shall submit any unusual incident reports to the licensing agency by the next working day and a written report to be submitted to the licensing agency within seven days following the date of the incident.
· LPA has observed that the facility has been reporting incidents timely and submitting the required information to the licensing agency appropriately.
LPA observed facility to be in compliance. No deficiencies are being cited. 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: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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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