<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700531
Report Date: 04/12/2023
Date Signed: 04/12/2023 05:30:06 PM


Document Has Been Signed on 04/12/2023 05:30 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:A1 MAGNIFICENT HOMEFACILITY NUMBER:
342700531
ADMINISTRATOR:GAERLAN, LEONIDAFACILITY TYPE:
740
ADDRESS:3311 MISSION AVENUETELEPHONE:
(916) 335-5831
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:5CENSUS: 2DATE:
04/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Leonida GaerlanTIME COMPLETED:
05:30 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
On 4/12/23, Licensing Program Analyst (LPA) Kevin Mknelly,conducted an unannounced inspection. LPA met with Licensee and explained the purpose of the visit.

The purpose of this inspection was to follow-up on incident report and death notification, received on 4/7/23, for incidents 4/1/23 and death on 4/3/23.

LPA conducted an inspection and observed residents to be assisted as needed. Interview was conducted with licensee and caregiver.

On 4/1/23 R1 called for assistance on three occasions and was found on the floor. On the instances R1 reported to have no injuries and denied needing medical care. On 4/2/23, R1 was at baseline with no decrease in function and no increases in pain. On 4/3/23, R1 signed out of the facility at 10:50 am for a supposed Dr. appt. By report of the friend, there was not an actual Dr. appt. scheduled for 4/3/23. R1's friend returned with R1 at approximately 5:50 and informed caregiver that R1 was unresponsive in the friend's vehicle. Emergency responders were notified, CPR was administered. Emergency responders pronounced R1 deceased. The death does not appear related to the falls of 4/1/23 at this time.

LPA asked that licensee resubmit the death report and ID/ Emergency form.

As a result of today’s inspection, no deficiencies were noted. This report was reviewed and copy provided.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1