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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315001898
Report Date: 03/28/2023
Date Signed: 03/28/2023 04:49:46 PM


Document Has Been Signed on 03/28/2023 04:49 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:RESIDENCE HEALTHCARE-RCFEFACILITY NUMBER:
315001898
ADMINISTRATOR:ASHBURN, DARRINFACILITY TYPE:
740
ADDRESS:133 VALLEYWOOD WAYTELEPHONE:
(916) 788-4195
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 6DATE:
03/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Carmen Urzeala and Darrin Ashburn, Administrators TIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the full inspection care tool. LPA met with Kareen Ann Martin and Natalie Tucker, caregivers, who contacted Administrators Carmen Urzeala and Darrin Ashburn, by phone. Administrator arrived at 2:30 pm. LPA observed (5) clients in the common areas and (1) resident in her room at the start of the inspection. LPA completed the required COVID-19 Department protocols, was screened upon entry to the facility and was wearing a surgical mask. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (4). Currently, there is (1) resident on hospice.

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, staff room, kitchen, laundry and garage. LPA observed the facility to be clean, in good repair and odor-free. LPA observed each bathroom to have the necessary grab bars, non-skid flooring, paper towels, trash can with lid and 20-second hand-washing poster. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food and sharps and medications to be locked in the kitchen. All toxins are locked in the laundry area. LPA observed sufficient PPE/emergency supplies. The inside temperature measured 74*F. The fire extinguisher was last serviced on 3/17/23 and smoke/monoxide alarms were working. Discussed vaccination status of residents/staff. LPA observed the pool to be gated and locked. There is (1) unlocked gate on the inside back patio and outside seating. LPA reviewed (2) of (6) resident files and found them to contain current documentation. LPA reviewed (2) staff files and found them to contain current documentation of First Aid/CPR certification and other required trainings.. Hot water measured 115.6 *F in the kitchen. LPA observed all required postings to be posted , including Covid posters and facility visiting hours. Facility has an approved Infection Control Plan. RCFE Admin Certificates (2) are current and posted. All staff are cleared and associated to the facility.
An updated copy of liability insurance, LIC308 and LIC500 were obtained. There are no deficiencies observed during today's inspection. Exit interview. Copy of report provided to Administrators.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
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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