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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700273
Report Date: 09/21/2023
Date Signed: 09/21/2023 04:59:24 PM


Document Has Been Signed on 09/21/2023 04:59 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) 765-2952
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 6DATE:
09/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Luybov Frango, caregiverTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Luybov Frango, caregiver, and explained purpose of inspection. LPA was advised that the Administrator, Raisa Oselsky, was returning from out of town. The Administrator Designee, Eva Bogomaz, arrived at the facility shortly to assist with the tour and providing records for review. LPA observed (3) residents resting in the common area, and (3) residents in their rooms. Currently, there are (3) residents under hospice care. The Administrator arrived at 4:30 pm to complete the inspection.

LPA. caregiver and Administrator Designee toured the interior and exterior of the facility including the common areas, (6) private resident bedrooms, (2) bathrooms, staff room, kitchen, laundry area. The Administrator resides on the property as well. LPA observed the home to be clean, safe and in good repair and to not pose a health and safety risk. Inside temperature was observed to be 75*F. There is a front enclosed patio as well as backyard seating with shade. Fire extinguisher last serviced 5/17/23, and the smoke monoxide alarms are in working order. The facility conducts quarterly fire drills- last drill in July 2023. LPA observed sufficient 2+day perishable and 7+day non-perishable food and sufficient PPE on hand. LPA observed individual cloth towels, soap, sanitizer, trash cans, 20-second hand-washing posters. Administrator showed LPA a paper towel dispenser to be installed. Hot water temperature measured 110*F in the kitchen. There are locked sharps and toxins in the kitchen and additional toxins locked in the laundry area.

LPA reviewed (4) of (6) files and observed paperwork to be updated. Residents have all lived at the facility for at least two years. Facility uses a Medication Administration Record that is maintained correctly. The Administrator is a certified Pharmacy Technician and provides medication training to the staff. Additionally, a nurse from the Veterans Administration visits and checks medications and records for (3) every 3 weeks. LPA reviewed (3) staff files and observed First Aid/CPR to be current. Administrator certificate expires 12/19/23. Staff are in the process of completing (20) hours of ongoing annual training- (11) completed so far. Administrator to conduct a survey to see what residents' interests are. LPA to email LIC9282- due 9/30/23.
LPA obtained a copy of LIC308 and of the liability insurance and requested an updated LIC500 be provided to the Dept by 9/30/23.
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: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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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