<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002988
Report Date: 09/14/2023
Date Signed: 09/15/2023 08:19:07 AM


Document Has Been Signed on 09/15/2023 08:19 AM - 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:ROCKLIN SENIOR LIVINGFACILITY NUMBER:
315002988
ADMINISTRATOR:DOCMANOV, ANAMARIAFACILITY TYPE:
740
ADDRESS:5720 MORNINGSIDE CTTELEPHONE:
(916) 757-7057
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 6DATE:
09/14/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Ramona Iordache TIME COMPLETED:
05:00 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) Kevin Mknelly arrived at the facility unannounced on 914/23 to conduct a Post Licensing Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection.

Administrator designee arrived at the facility. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, 6 resident bedrooms, 3 bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and designee discussed acceptable ways to hold fire doors open, securing cleaning supplies in the laundry room with either locked cabinets or a locked door, securing potentially harmful items in staff living areas, medication procedures of identifying medications when removed from the container and documenting PRN use.

LPA reviewed 6 resident files. Files were complete. LPA and designee discussed bed rail orders when residents have hospital beds, having meetings with residents or responsible parties to review care plans and when LIC 602s are to be updated.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted. There were technical difficulties in capturing signatures and printing the report.

Report provided to licensee via email with request for signature.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1