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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700079
Report Date: 06/08/2023
Date Signed: 06/08/2023 11:17:33 AM


Document Has Been Signed on 06/08/2023 11:17 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:RETREAT AT ROYAL GREEN LLC, THEFACILITY NUMBER:
342700079
ADMINISTRATOR:TIN, ANTONETTEFACILITY TYPE:
740
ADDRESS:865 ROYAL GREEN AVENUETELEPHONE:
(916) 549-2724
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 5DATE:
06/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mylene ArceoTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 6/8/23 to conduct a Required - 1 Year visit at 9:45am. LPA met with Mylene Arceo, Caregiver who contacted the Administrator Antonette Tin regarding the purpose of todays visit. Administrator arrived within 15 minutes to assist with todays visit. Administrator Certificate expires 7/5/2024.

The facility is licensed for a capacity of 6 non-ambulatory of which 1 may be bedridden. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. During this visit LPA observed residents involved in their respective activities.

The temperature inside the facility was observed to be at 75*F which is within the required range of 68-85*F. The hot water temperature was measured at 116.1 *F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility.

Facility has a hospice waiver for 4 of which there is 1 resident receiving hospice services at this time.
LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308)
Personnel Report (LIC500)
Administrator Certificate-Updated

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
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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