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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700060
Report Date: 07/18/2022
Date Signed: 07/18/2022 01:31:40 PM

Document Has Been Signed on 07/18/2022 01:31 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:LEVENDI ESTATE, THEFACILITY NUMBER:
342700060
ADMINISTRATOR:BERCI, ADRIANFACILITY TYPE:
740
ADDRESS:4107 LEVENDI LNTELEPHONE:
(916) 333-4641
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY: 6CENSUS: 6DATE:
07/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH: Romona Dellroy TIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 07/18/2022 at 12:45 PM. LPA met with Romona Dellroy and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

The facility is licensed for 6 bed ridden residents, and has a hospice waiver for four. There are currently 6 residents who reside at this facility, which there are one residents receiving hospice services.

The LPA toured the facility with the Romona Dellroy on 07/18/2022 at 1:00 PM.

The facility has one central screening entry point. The facility has submitted a LIC 808 mitigation plan and Infection Control plan. The facility has a designated area for visit. The facility has covid-19 postings. The facility has hand sanitizer throughout the facility. The facility common areas, bathrooms, and resident rooms are sanitary and furnished. The facility fire extinguishers are up to date and fire drill was conducted. The last fire inspection was conducted in March of 2022. The exterior of the facility is sanitary and clear of debris. The exterior exit door is in good repair.

There were no deficiencies observed or cited at this annual inspection visit. An exit interview was conducted, and a copy of this 808 report was given to Romona Dellroy.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2022
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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