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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005454
Report Date: 10/30/2020
Date Signed: 10/30/2020 06:51:11 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:A-1 ELDERLY CAREFACILITY NUMBER:
317005454
ADMINISTRATOR:EMIL TIFFACILITY TYPE:
740
ADDRESS:103 MCLAREN COURTTELEPHONE:
(916) 472-6432
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 5DATE:
10/30/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
06:00 PM
MET WITH:Simona Tif, Administrator TIME COMPLETED:
07:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a health and safety check. LPA met with Robert Tif, caregiver, who was outside facility and had just arrived at time of LPA's arrival. LPA met with Simona Tif, Administrator, upon entering the facility. LPA wore N95 mask and was screened shortly after entering the facility. The purpose of today's inspection was to follow up on the health and safety of (3) residents who recently relocated, on 10/23/20, to this facility from a related facility, where Robert Tif is currently Administrator of.

LPA toured the inside of the facility with Robert Tif and observed all (5) residents to be in their bedrooms, sleeping or watching television. Administrator Simona confirmed that residents ate dinner prior to LPA's arrival. LPA spoke with resident (R1) who had relocated and indicated that he is doing well. Resident (R2) was sleeping during today's inspection. Resident (R3) was awake and watching television from his bed and indicated he is doing well currently. Both R1 and R3 stated they are treated well and have no complaints. LPA observed a walker in R1's room and a wheelchair in R2 and R3's room. Administrator Simona stated that both R2 and R3 can walk with assistance but will use a wheelchair if they are tired or want to go outside. LPA observed residents (R4 and R5) to share bedroom #6 and to be awake and watching television.

LPA checked food supply and observed a sufficient 2+ day perishable and 7+day non-perishable supply on hand. LPA checked PPE supply and observed multiple masks, gloves and extra sanitizer, as well as a thermometer on hand. LPA observed all rooms to be clean, in good repair and free of clutter. LPA observed Covid-19 posters in bathrooms and in front entrance area. LPA observed resident file folders for residents R1 and R3. Robert Tif stated he would pick up resident R2's file by tomorrow that was at the facility he moved from.

There are no deficiencies being cited today.

Exit interview. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
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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