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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001444
Report Date: 07/25/2024
Date Signed: 07/25/2024 04:21:17 PM


Document Has Been Signed on 07/25/2024 04:21 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:HIDDEN LAKE CARE HOMEFACILITY NUMBER:
315001444
ADMINISTRATOR:COPACIU, LYDIAFACILITY TYPE:
740
ADDRESS:8405 ACORN DRIVETELEPHONE:
(916) 303-3896
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:6CENSUS: 3DATE:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Lydia Copaciu, Administrator TIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to conduct a Required annual Inspection. LPA met with Lydia Copaciu, Administrator, and Eugene Copaciu, staff, stating the reason for today's inspection. LPA observed (1) resident present in the common area and (2) residents in their rooms. Currently, there is (1) resident on hospice. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver approved for (4) residents.

LPA and Administrator toured the interior/exterior of the facility including common areas, (3) resident bedrooms, (2) resident bathrooms, kitchen, laundry/garage area. The upstairs area is used by staff. LPA observed the facility to be clean, in good repair and odor-free, and each bathroom has the necessary grab bars, non-skid flooring, paper towels, trash can with lid and 20-second hand-washing poster. Medications are locked in a designated closet, and toxins are locked in the kitchen/laundry area. The inside temperature measured 81*F and the hot water measured 110*F in the kitchen. Sharps are locked in kitchen. There is 2+day perishable food, including fresh produce, and 7+ day non-perishable food. There are sufficient paper products/PPE/linens/towels and (2) complete First Aid kits, including flashlights. Smoke/monoxide alarms are working and the fire extinguisher was recently purchased. Quarterly fire drills are documented- last drill April 2024. Outside, there is a covered patio table with chairs, and sufficient outdoor space. There are two open, unlocked exits for evacuation. Emergency Disaster and Infection Control Plans were reviewed. Required postings are in the common area. Current copy of liability insurance obtained.

LPA reviewed resident files/medications for (2) residents. Paperwork was organized, current and orders match medications being administered. Medications are logged when received/started. (2) staff files were reviewed. Both staff are cleared/associated, have completed required training, including First Aid/CPR. Admin #6019705740- exp 9/11/24. LIC308 and LIC500 to be submitted by 7/3124.
There were no deficiencies observed.
Copy of report provided during exit interview.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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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