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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097002879
Report Date: 08/22/2023
Date Signed: 08/22/2023 10:39:03 AM


Document Has Been Signed on 08/22/2023 10:39 AM - 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:WHISPERING PINEFACILITY NUMBER:
097002879
ADMINISTRATOR:SEREDA, IRINAFACILITY TYPE:
740
ADDRESS:1666 DOWNIEVILLE COURTTELEPHONE:
(916) 939-3784
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:6CENSUS: 6DATE:
08/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Irina SeredaTIME COMPLETED:
10:50 AM
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On 08/22/2023, Licensing Program Analysts (LPAs) Jaynae Boyles and Lavinia Muscan arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPAs met with Facility Administrator Irina Sereda and explained the purpose of the visit.

LPAs Boyles, Muscan and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, and common restrooms. LPA's observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 115 F. LPA observed one (1) fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of three (3) residents' files and three (3) staff files.

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) 917-3040
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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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