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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700273
Report Date: 09/06/2024
Date Signed: 09/06/2024 03:48:13 PM


Document Has Been Signed on 09/06/2024 03:48 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SIDNEY HOME CAREFACILITY NUMBER:
342700273
ADMINISTRATOR:OSELSKY, RAISAFACILITY TYPE:
740
ADDRESS:7332 SIDNEY DRIVETELEPHONE:
(916) 560-3148
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 6DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Raisa Oselsky, Administrator TIME COMPLETED:
03:45 PM
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
Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with caregiver and Administrator Designee, Eva Bogomaz, and explained purpose of inspection. LPA met with Administrator, Raisa Oselsky, who arrived shortly. LPA observed (4) residents watching television in the common area, and (2) residents resting in their rooms. There is an approved hospice waiver for (3) residents. Currently there is (1) resident under hospice care.

LPA and Administrator toured the interior and exterior of the facility including the common areas, (6) private resident bedrooms, (2) bathrooms, staff area, kitchen, laundry area. LPA observed the home to be clean, safe and in good repair and to not pose any health or safety risks. Inside temperature measured 75*F. There is a front enclosed patio, backyard seating with shade, and a walking path. Fire extinguisher last serviced 5/8/24, and the smoke monoxide alarms are in working order. The facility conducts quarterly fire drills. There is sufficient 2+day perishable and 7+day non-perishable food. Sharps and medications are locked in the kitchen and toxins are locked in the nearby laundry area. Hot water measured 105*F in kitchen. Bathrooms have the necessary grab bars, non-skid flooring, soap, paper towels, trash can with lid and 20-second hand-washing poster. There is a complete First Aid kit and linens/towels/blankets/PPE on hand.

LPA reviewed (3) of (6) resident files and observed paperwork to be current and organized. Medications were reviewed for (1) resident and orders match medications being administered. Medication documentation is current. LPA reviewed (3) staff files and observed First Aid/CPR to be current. Administrator certificate #7002431740- expires 12/19/25. Staff are in the process of completing the required annual training. Copy of HSC 1569.625 and HSC 1569.69 provided.

LPA received an updated copy of liability insurance. LPA requested an updated copy of LIC500 and LICC308 be provided to the Dept by 9/13/124. There were no deficiencies noted in today's inspection.
Exit interview. Copy of report provided to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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