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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700338
Report Date: 09/12/2024
Date Signed: 09/12/2024 11:47:01 AM


Document Has Been Signed on 09/12/2024 11:47 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SIGNATURE LIVING ON STORY RIDGE WAYFACILITY NUMBER:
342700338
ADMINISTRATOR:RIMANDO, NORAFACILITY TYPE:
740
ADDRESS:8400 STORY RIDGE WAYTELEPHONE:
(916) 300-5363
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 6DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Administrator- Nerryrose Rimando-AfableTIME COMPLETED:
11:50 AM
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On 09/12/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a required 1 year annual inspection. LPA met with Administrator Nerryrose Rimando-Afable and explained the purpose of the visit.

LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to six (6) resident private bedrooms, two (2) bathrooms, kitchen, common areas, and storage area. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. Hot water temperature was measured at 116.4 degrees Fahrenheit at the kitchen sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 75 degrees. LPA observed fire detectors and carbon monoxide detectors to be operable. LPA observed the fire extinguisher, located in kitchen, which was last inspected on 06/04/2024. LPA reviewed drill logs, which are conducted quarterly. LPA observed required Licensing posters posted throughout the facility.

LPA reviewed six (6) resident files and three (3) staff files all files contained the required documents. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for two (2) residents. Facility is correctly using the Medication Administration Records (MAR).

LPA requested Administrator to send updated copies of the following by 09/17/24 to LPA
  • LIC308- Designation of Administrative Responsibility
  • LIC500- Personnel Report
  • Liability insurance
No deficiencies are being cited during today's inspection.

Exit interview conducted and copy of the report was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
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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