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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700679
Report Date: 09/27/2023
Date Signed: 09/27/2023 11:13:09 AM


Document Has Been Signed on 09/27/2023 11:13 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:A&C ELDERLY CAREFACILITY NUMBER:
342700679
ADMINISTRATOR:ION, CARMENFACILITY TYPE:
740
ADDRESS:3319 SCOTLAND DRIVETELEPHONE:
(916) 223-5435
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 5DATE:
09/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Ion CarmenTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Talwinder Bains arrived on 09/27/23 to conduct the annual inspection.
LPA met with administrator, Ion Carmen who assisted LPA during today's inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed residents (2) and staff files (2). All residents files contained the required paperwork. Staff file contained the required paperwork. Staff have current first aid and CPR training. Facility was clean. All required postings were observed. LPA reviewed medications of 2 residents comparing with physician orders and find no errors.

LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included residents rooms, bathrooms, kitchen, common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. All exits were unobstructed. The administrator's certificate is current. There is a gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use . Water temperature is within compliance (112 degree F) .Inside temperature was observed to be 74 degree F. In the areas toured, there were no health or safety violations were observed.

LPA requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by 10/15/23.

No deficiencies were observed or cited during today's visit.
Exit interview conducted. A copy of this report was printed and given to Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023
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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