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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 052700992
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:32:06 PM


Document Has Been Signed on 11/27/2023 03:32 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:FOOTHILL VILLAGE SENIOR LIVINGFACILITY NUMBER:
052700992
ADMINISTRATOR:MARY MCCLUREFACILITY TYPE:
740
ADDRESS:1400 FOOTHILL VILLAGE DRIVETELEPHONE:
(805) 801-0404
CITY:ANGELS CAMPSTATE: CAZIP CODE:
95222
CAPACITY:78CENSUS: 74DATE:
11/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Kim GerhmannTIME COMPLETED:
03:45 PM
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On 11/27/23 at approximately 3:15pm, Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management for an incident report received. LPA Jensen met with business manager Kim Gerhmann and explained the purpose of the visit.

LPA Jensen reviewed an incident report that was sent on 11/25/23 for an incident wherein Resident 2 (R2) was feeling ill and vomiting on 11/23/23. R2 was transported to the hospital and had not been discharged by the time the report was sent. LPA Jensen asked if R2 has returned to the community and was advised he has not. LPA Jensen inquired as to whether the facility staff is aware of his diagnosis and it was confirmed through interview they are not aware of R2's diagnosis. LPA asked staff to follow up for the purposes of ruling out infectious disease or taking the necessary precautions if needed for infectious disease. Facility staff followed up with the discharge nurse and determined R2 was not diagnosed with infectious disease and will return to the community shortly.

No deficiencies were observed. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023
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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