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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700525
Report Date: 08/05/2024
Date Signed: 08/05/2024 11:00:40 AM


Document Has Been Signed on 08/05/2024 11:00 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: 110DATE:
08/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH: Administrator Stephen MacdonaldTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 08/05/24 to do case management visit . LPA met with Administrator , Stephen Macdonald and explained the purpose of the visit.

Incident for Resident, R1- Department followed up on Incident Report and SOC 341 sent by facility on 07/19/24 stating that resident, R1 reported to staff on 07/18/24 around 8AM that staff, S1 was rough with them while providing care to R1 on 07/18/24 during morning shift care. Facility notified law enforcement regarding this incident and there were no findings. Facility also notified R1s physician, LTCO and responsible party regarding this incident. Facility Nurse checked R1 for any injurers and none were present.

Incident for Residents, R2 and R3 - Department followed up on Incident Report and SOC 341 sent by facility on 07/22/24 regarding an incident which happened between 2 residents (R2,R3) during dinner time around 6pm on 07/21/24. Incident report stated that R2 was at dining room table, when R3 walked up and began to move the cups around. R2 began to yell at R3 to get away from the table. R3 was observed throwing a cup at R2 and it hit R2 above their lip, causing a small cut. R3 was redirected to another area. Med tech was notified, and the cut was cleaned and covered for R2. Facility notified R2s and R3s physician, LTCO and responsible party regarding this incident.

Department conducted interviews with 3 residents during today's visit and requested documents from staff,S1s file and facility shall send all requested documents to LPA via email by 08/06/24 by 5pm.

At this time, these incidents are under review and department will do follow up if warranted.
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: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
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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