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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700525
Report Date: 05/29/2024
Date Signed: 05/29/2024 11:01:32 AM


Document Has Been Signed on 05/29/2024 11:01 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:ALMOND HEIGHTSFACILITY NUMBER:
342700525
ADMINISTRATOR:MACDONALD, STEPHENFACILITY TYPE:
740
ADDRESS:8685 GREENBACK LNTELEPHONE:
(916) 542-7988
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:145CENSUS: 108DATE:
05/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator,Stephen Macdonald TIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/29/24 to do case management visit . LPA met with Administrator, Stephen Macdonald and explained the purpose of the visit.

Department followed up on SOC 341 sent by facility on 05/24/24 for date -05/20/24 regarding resident, R1 where R1 alleged that R1 fell into the bed on 05/20/24 around 10.30pm when staff S1 and S2 were assisting them. Facility notified R1s responsible party, law enforcement and long term care ombudsman (LTCO) regarding this incident. Per facility records, there were no visible injuries to R1 after this incident. Per facility’s staffing records, S1 was not working on 05/20/24. LPA conducted interview with resident, R1 regarding this incident during today’s visit. LPA attempted to interview S2 but found out that S2 was not working today.

LPA requested documents related to this incident and facility will submit all documents by 05/31/24 by 5pm.

At this time, this case in under review and department will do follow up as needed.
No citations were issued per Title 22 Regulations.
Exit interview conducted and copy of the report left at facility.





SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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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