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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002873
Report Date: 03/12/2024
Date Signed: 03/12/2024 12:39:42 PM

Document Has Been Signed on 03/12/2024 12:39 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:CIRBY RANCH SRFFACILITY NUMBER:
315002873
ADMINISTRATOR:OKOLO, SAFARATUFACILITY TYPE:
772
ADDRESS:1085 SANDRINGHAM WAYTELEPHONE:
(916) 870-9676
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY: 6CENSUS: 3DATE:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Regional Director, Rachel Breedlove TIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived on 03/12/24 to conduct the annual inspection. LPA met with Regional Director (RD) , Rachel Breedlove and explained the purpose of today's visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed residents (2) and staff files (2). Facility was clean and well organized. All required postings were observed. Residents files found to be complete. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for two (2) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR).

LPA and RD toured the facility together to ensure the health and safety of residents in care. The areas toured included residents rooms, bathrooms, kitchen ,office area common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher was last serviced on 01/08/24 and was ready for emergency use. Hot water temperature was observed to be 110 degrees F, which is within the regulation range of 105-120 degree. Inside temperature was observed at 70 degree F.


No deficiencies were observed or cited per Title 22, CCR Regulations from this visit.
Exit interview conducted. Copy of this report was provided to RD.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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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