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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317817
Report Date: 05/29/2024
Date Signed: 05/30/2024 07:31:12 AM


Document Has Been Signed on 05/30/2024 07:31 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/30/2024 07:29 AM

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

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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced health and safety check visit at facility. LPA met with administrator and explained purpose of the visit.

This facility is a single story building licensed to serve ten (10) non-ambulatory residents.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. Centrally stored medication logs are maintained for residents at facility. Physician signed and dated for each written order for residents. Maintenance of facility including clean, safe, sanitary, and good repair at all times; licensee is ensuring for residents, employees, and visitors.

LPA did not observe any hazards or lack of care and supervision during this visit. All chemicals are safety locked up and inaccessible for residents.

LPA reviewed staff records and initial and training was documented as required for personnel requirements for senior care facilities.

Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies observed or cited today.

Exit interview conducted with administrator. A copy of report left at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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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