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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700396
Report Date: 02/15/2024
Date Signed: 02/15/2024 02:33:19 PM


Document Has Been Signed on 02/15/2024 02:33 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:LOVE & CARE FOR ELDER IIFACILITY NUMBER:
342700396
ADMINISTRATOR:SUIUGAN, ELIZABETHFACILITY TYPE:
740
ADDRESS:7990 COOK RIOLO RDTELEPHONE:
(916) 723-2912
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 6DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator -Elizabeth SuiuganTIME COMPLETED:
02:40 PM
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On 02/15/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with staff, Ben Szabo, and explained the purpose of the visit. LPA requested for staff to notify administrator of LPA's presence at the facility. Administrator, Elizabeth Suiugan arrived at the facility shortly after.

LPA and staff conducted a tour of the facility. Areas toured included but not limited to the kitchen, dining room, five (5) residents bedrooms, bathrooms, common areas and backyard. LPA observed sufficient furniture and lighting throughout the facility. During the tour LPA observed three (3) residents in their bedrooms and three (3) residents in common areas.

LPA observed the facility to have sufficient food supplies for seven (7) day non-perishable and two (2) day perishable. LPA observed toxins, knives and centrally stored medications to be locked and inaccessible to residents in care. All required Licensing posters are present in common area in the facility. Hot water temperature was measured at 109 degrees Fahrenheit at the kitchen sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 71 degrees. Fire extinguishers was last inspected on 11/10/23. Smoke and carbon monoxide detectors are working and present throughout the facility. First Aid kit is maintained and ready for emergency use.

LPA conducted a file review of four (4) resident files. LPA compared medications to those being given for two (2) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). Additionally, LPA reviewed two (2) personnel records which had all required documents.

LPA requested a copy of the current liability insurance to be sent to LPA Ratajczak by 02/29/24.

LPA completed the full care tool and no deficiencies was observed.
Exit interview conducted and a 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: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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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