342700670-7-30-2021-27-AS-VBRN-C5EULR-20210730154111

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700670
Report Date: 07/30/2021
Date Signed: 07/30/2021 03:41:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	LATER YEARS SENIOR CARE HOME		FACILITY NUMBER:	342700670
ADMINISTRATOR:	ORNELLAS, MARITES		FACILITY TYPE:	740
ADDRESS:	14 ARARAT CT		TELEPHONE:	(916) 538-6096
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	6	CENSUS: 6	DATE:	07/30/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Ruperto Rosario		TIME COMPLETED:	04:00 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 and Brittney Ross, Seasonal Clerk arrived unannounced to conduct a Required - Annual visit on 7/30/21 at 11:45am. The Administrator Certificate expires on 3/22/2022. LPA met with Ruperto Rosario, Caregiver and Regina Rosario who assisted with todays visit. LPA discussed the purpose of the visit. Licensee was notified of the visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which 3 may receive hospice services. There is 2 residents receiving hospice services at this time. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed and interviewed a random amount of residents who were engaged in lunch and individual activities during this visit. See 809C for continuation...

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LATER YEARS SENIOR CARE HOME	FACILITY NUMBER: 342700670
	VISIT DATE: 07/30/2021

NARRATIVE

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809 continued...

LPA observed 2-day perishables and 7-day non-perishables.

The temperature inside the facility was observed to be at 75*F which is within the required range of 68-85*F. The hot water temperature was measured at 107.9 *F which is within the required range of 105-120*F. LPA observed a 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.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308)
LIC610E to be updated
Liability Insurance
Administrator Certificate-Updated
Personnel Report (LIC500)
Facility Roster to be updated
Administrative Organization LIC309

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

LIC809 (FAS) - (06/04)

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