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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700574
Report Date: 09/21/2023
Date Signed: 09/21/2023 03:50:57 PM


Document Has Been Signed on 09/21/2023 03:50 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:ANSEL PARK SENIOR LIVING COMMUNITYFACILITY NUMBER:
312700574
ADMINISTRATOR:DEBORAH TAYLORFACILITY TYPE:
740
ADDRESS:1200 ORCHID DRIVETELEPHONE:
(916) 250-0770
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:100CENSUS: 78DATE:
09/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Deborah Taylor, Executive DirectorTIME COMPLETED:
04:00 PM
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On 9/21/2023 LPA Tryon visited the facility to do an annual visit using the CARE Tool. LPA met with Executive Director Deborah Taylor.

LPA toured the facility including common areas, dining room, kitchen, resident apartments, bathrooms, hallways, med rooms, laundry rooms, outdoor areas.
The facility is clean and nicely decorated throughout. Apartments are appropriately furnished. Smoke detectors/fire alarm system/carbon monoxide detectors installed and functioning, system is checked on a regular basis quarterly and maintained. Fire extinguishers present in various locations and charged.

Medications are centrally stored and locked in med carts, as well as med room doors being locked. Medications are stored in original pharmacy containers/packs and labeled by pharmacy. Centrally stored medication logs are maintained as well as MARS electronically..

LPA reviewed 8 resident files and 5 staff files. Files include appropriate documentation. Staff have criminal record clearance and appropriate training documentation. Resident files include physician reports, updated care plans, contact information, etc.

LPA reviewed the CARE Tool with the ED.

At this time, the facility appears to be in substantial compliance with Title 22 and Health and Safety Code.

No deficiencies were cited at this visit. Exit interview conducted.

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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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