342700380-1-10-2024-27-AS-VBRN-CZCU7E-20240110141949

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700380
Report Date: 01/10/2024
Date Signed: 01/10/2024 02:19:55 PM

Document Has Been Signed on 01/10/2024 02:19 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	GATCHALIAN CARE HOME		FACILITY NUMBER:	342700380
ADMINISTRATOR:	GATCHALIAN, AURORA M		FACILITY TYPE:	740
ADDRESS:	8720 THETFORD CT		TELEPHONE:	(916) 685-4334
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 6	DATE:	01/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Grant Depositar		TIME COMPLETED:	02:30 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) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 1/10/2024 at 8:45am. LPA met with Grant Depositar, Designee/Administrator and stated the purpose of the visit. Caregivers present are fingerprint cleared and associated to the facility. The facility is licensed for a capacity of 6 Non-ambulatory residents of which 1 maybe bedridden and 4 may receive hospice care services. There is 1 bedridden resident and 2 residents receiving hospice care services at this time. Administrator Certificate expires 8/18/24 for Grant Depositar. The license fees are due 1/28/24 and the pin number was given as an option to pay online during this visit. LPA observed a copy if the Infection Control Plan during this visit. 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. The temperature inside the facility was observed to be at 74 F which is within the required range of 68-85F. The hot water temperature was measured at 120.0F which is within the required range of 105-120F. LPA observed pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. 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. The most recent emergency drill was conducted on 12/29/2023. LPA reviewed 2 staff and 2 resident files and conducted interviews during this visit.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GATCHALIAN CARE HOME	FACILITY NUMBER: 342700380
	VISIT DATE: 01/10/2024

NARRATIVE

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Upon a file review the following items were discussed to be submitted with any changes annually:
Licensing fees-Pin number provided
Criminal Record Clearances LIS536-Current
Administrative Organization LIC309-Current
Designation of Administrative Responsibility LIC308-Submit
Personnel Report LIC500-Submit
Affidavit Regarding Client/Resident Cash Resources LIC400-NA
Surety Bond LIC402-NA
Facility Floor Plan/Plot Plan LIC999-Current
Fire Clearance (consistent with terms and limitations of license)-Current
Qualifications of Administrator/Facility Manager-Submit
Articles of Incorporation/Organization, Constitution and bylaws-Current
Partnership Agreement-NA
Control of Property-Submit
Emergency Disaster Plan LIC610-Submit
Plan of Operation (Restricted Health Care Plan)-Submit if needed
Admission Policies and Procedures-Current
Health Screening Report-Facility Personnel LIC503-Current
Bacteriological Analysis of Private Water Supply-Current
In-service Training Program-Current
Medication Procedures-Current
Transportation Procedures-Current
Job Description/Personnel Policies-Current
Exemptions/Waivers and Exceptions-Current
First aid/CPR certificates-Current
-Any updates to Infection Control Plan

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC809 (FAS) - (06/04)

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