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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005563
Report Date: 12/06/2023
Date Signed: 12/06/2023 10:17:07 AM


Document Has Been Signed on 12/06/2023 10:17 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:HAMPSHIRE MANOR INCFACILITY NUMBER:
317005563
ADMINISTRATOR:CATHY DUSTINFACILITY TYPE:
740
ADDRESS:1203 HAMPSHIRE COURTTELEPHONE:
(916) 742-5386
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 6DATE:
12/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Executive Director: Cathy Dustin TIME COMPLETED:
10:25 AM
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
On 12/6/2023 at 8:45 AM, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Executive Director (ED), Cathy Dustin, and explained the purpose of the visit. LPA observed a total of six (6) residents in care and one (1) staff present at the facility during the annual inspection.

At 9:15 AM, LPA and ED toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, garage and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. Toxic and cleaning supplies locked and is inaccessible to residents in care. The hot water temperature was measured in the kitchen at 105 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. LPA observed two (2) fire extinguishers located in the kitchen and garage. Fire extinguishers were last serviced on 9/1/2023. Fire drill was last conducted on 10/23/2023. LPA observed medications to be locked and inaccessible to residents in care. LPA observed required Licensing posters posted throughout the facility.

At 9:35 AM, LPA reviewed a total of three (3) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for three (3) residents and found no discrepancies. LPA reviewed a total of one (1) staff record. Staff has training in first aid and CPR, medication management, restricted health conditions, posture support, hospice care, and other various areas of care provision.

LPA request for ED to submit the following to Community Care Licensing for review.
  • Liability Insurance

No deficiencies being cited during today's inspection. Exit interview conducted and report provided
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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