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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700338
Report Date: 09/05/2023
Date Signed: 09/05/2023 01:22:29 PM


Document Has Been Signed on 09/05/2023 01:22 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: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:
09/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Administrator- Scott Afable TIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived on 09/05/2023 to conduct the annual inspection.
LPA met with administrator, Scott Afable who assisted LPA during today's inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed residents (2) and staff files (2). All residents files contained the required paperwork. Staff file contained the required paperwork. Staff have current first aid and CPR training. Facility was clean. All required posting were observed. Staff training contained the required initial and annual training. LPA reviewed medications of 2 residents comparing with physician orders and find no errors.

LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included residents rooms, bathrooms, kitchen, common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. All exits were unobstructed. There is a gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use and was last serviced on 05/26/23 . Water temperature is within compliance (114 degree F) .Inside temperature was observed to be 73 degree*F. In the areas toured, there were no health or safety violations observed.

LPA requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by 09/15/23.

No deficiencies were observed or cited during today's visit.
Exit interview conducted. A copy of this report was printed and given to Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
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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