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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317001897
Report Date: 03/23/2023
Date Signed: 03/23/2023 04:24:58 PM

Document Has Been Signed on 03/23/2023 04:24 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:SIERRA SUMMIT HEAD INJURY CAREFACILITY NUMBER:
317001897
ADMINISTRATOR:PENNY MEARSFACILITY TYPE:
735
ADDRESS:5562 MONTCLAIR DRIVETELEPHONE:
(916) 632-9622
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY: 6CENSUS: 4DATE:
03/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Penny Mears, Administrator TIME COMPLETED:
04:30 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 Angel Bowns, caregiver, who contacted Administrator, Penny Mears, by phone. Administrator arrived at 2:00 pm. LPA observed (3) clients in the common areas 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 that are medically fragile due to head trauma.

LPA and Administrator toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms, (1) shared resident bedroom, (2) resident bathrooms, kitchen, laundry area 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 lids and 20-second hand-washing poster. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food and sharps and toxins to be locked. Medications were locked nearby in the medication room. LPA observed sufficient PPE/emergency supplies in the garage. The inside temperature measured 75*F. The fire extinguisher was last serviced on 8/1/22 and smoke/monoxide alarms are serviced yearly. Discussed vaccination status of residents/staff- booster flyer provided. LPA observed (2) unlocked gates from the inside back patio and patio area with seating. LPA reviewed (2) of (4) resident files and found them to contain current documentation. LPA reviewed (3) staff files and found them to contain current First Aid/CPR training as well as documentation of monthly staff training, including on Infection Control Plan. . All (8) staff have been FIT tested for N95 masks. LPA reviewed the Infection Control Plan and found it to be very extensive. Hot water measured 115*F in the kitchen. LPA observed required postings to be posted , including Covid posters, and a large daily activity calendar. Next Resident Council Meeting date also posted as well as House Rules and Resident Rights in each resident room. Reviewed Emergency Disaster plan which was reviewed/updated 1/3/23. LPA requested an updated copy of the LIC308. LIC500 be sent to CCLD by 3/31/23. There are no deficiencies issued during today's inspection. Exit interview. Copy of report provided to Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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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