312700277-3-9-2023-59-AS-SCAA-CPS25J-20230309160537

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 312700277
Report Date: 03/09/2023
Date Signed: 03/09/2023 04:05:46 PM

Document Has Been Signed on 03/09/2023 04:05 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME:	COMPASSION CARE		FACILITY NUMBER:	312700277
ADMINISTRATOR:	MARIUT, ANA		FACILITY TYPE:	740
ADDRESS:	409 YALE DRIVE		TELEPHONE:	(916) 666-7297
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95678
CAPACITY:	6	CENSUS: 6	DATE:	03/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Ana Mariut, Administrator		TIME COMPLETED:	04:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the full care inspection tool. , LPA was greeted by Roberta Morgan, Caregiver, and explained the purpose of the inspection. Caregiver contacted Ana Mariut, Administrator, who arrived at 1:15 pm. . LPA observed a second caergiver, Deloris Wade-Rowe also present during the inspection. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols, wore a surgical mask and was screened per Covid-19 precautionary measures upon entering the facility. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (3). Currently there are no residents receiving hospice services. LPA observed (2) residents in the common area and (4) residents to be in their rooms resting at the start of the inspection. LPA and Administrator toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms, (1) shared resident bedroom, (2.5) resident bathrooms, kitchen, office, staff room, laundry area and garage. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels, trash cans with lids and 20-second hand-washing poster. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food and locked sharps and toxins in the kitchen. LPA observed locked medications in the office area. LPA observed sufficient PPE supplies in the garage. LPA observed the inside temperature to be 73F. The fire extinguisher was last serviced on 1/31/23.. Discussed vaccination status of residents/staff and eligibility for boosters. LPA observed (1) unlocked gate from the inside back patio and a covered patio area with seating. LPA reviewed (2) of (6) resident files and found them to contain current documentation- the care plan was updated recently but is waiting for family signatures. LPA reviewed medication orders to medications administered for these same (2) residents and found no discrepancies. LPA reviewed (4) of (4) staff files and found all staff to be cleared and associated to the facility and to have current First Aid/CPR training and the required initial/ongoing training. Administrator is waiting for an updated copy of RCFE Admin #6016203740- exp 4/17/22. cont on 809C..*

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: COMPASSION CARE	FACILITY NUMBER: 312700277
	VISIT DATE: 03/09/2023

NARRATIVE

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809C(1)... LPA and Administrator reviewed Infection Control Plan and a copy was provided to the Department during today's inspection. LPA observed cameras in the common areas of the facility and all required postings to be posted at the facility.

LPA printed an updated copy of the facility license during today's inspection to reflect an approved hospice waiver for (3) residents.

LPA requested an updated copy of the LIC308. LIC500 and current liability insurance during today's inspection by 3/17/23.

There are no deficiencies issued during today's inspection; however, a Technical Advisory Note is being issued on the LIC9102TA.

Exit interview. Copy of report provided to Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC809 (FAS) - (06/04)

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