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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315003019
Report Date: 09/07/2023
Date Signed: 09/07/2023 10:43:04 AM


Document Has Been Signed on 09/07/2023 10:43 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:A1 SENIOR CARE 3FACILITY NUMBER:
315003019
ADMINISTRATOR:PACATANG, BARBRAFACILITY TYPE:
740
ADDRESS:421 ASHWOOD WAYTELEPHONE:
(279) 336-1702
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 0DATE:
09/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Daisy PyrrhusTIME COMPLETED:
11:00 AM
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On Thursday September 7, 2023, Licensing Program Analyst Melissa Parks arrived to conduct a prelicensing inspection without residents in care.

LPA toured the facility with Licensee Daisy Pyrrhus and Administrator Barbara. This facility has a fire clearance for 6 nonambulatory residents. This facility also has a pending Dementia program. LPA observed audible alarms on all facility doors. There are 5 resident bedrooms and 3 bathrooms. Showers have required nonskid mats. Kitchen is clean and organized. All knives and sharp objects are kept inaccessible to residents. All appliances in the kitchen are observed to be clean and operational. Toxins and cleaning supplies will be kept inaccessible to residents in the laundry room. Medications are to kept locked in a cabinet in the kitchen. Backyard was clear of debris and hazards.

Facility has one fire extinguishers located in the kitchen. Facility has a fully stocked first aid kit.

Component III has been completed at this time with Administrator Barbara.

The facility appears to be in substantial compliance and ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau.

An exit interview was conducted with Licensees and a copy of this report was emailed to the facility.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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