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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700679
Report Date: 11/07/2024
Date Signed: 11/07/2024 01:45:12 PM

Document Has Been Signed on 11/07/2024 01:45 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:A&C ELDERLY CAREFACILITY NUMBER:
342700679
ADMINISTRATOR/
DIRECTOR:
CLAUDIA ADINA STANFACILITY TYPE:
740
ADDRESS:3319 SCOTLAND DRIVETELEPHONE:
(916) 223-5435
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Administrator- Carmen IonTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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On 11/07/24 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to conduct a Required 1 year annual inspection utilizing the care tool. LPAs met with Administrator Carmen Ion and explained the purpose of the visit. Facility currently has five (5) resident and a has a hospice waiver for three (3) residents. There is currently no residents receiving hospice services

LPAs and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but are not limited to: resident bedrooms, bathrooms, common areas, kitchen, garage and backyard. LPAs observed required furniture, and lighting throughout the residents' bedrooms and facility. LPAs observed residents' bathrooms to be clean, sanitary, and in good repair. LPAs observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies locked are inaccessible to residents in care. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher, which is located in the kitchen, was last serviced on 03/29/2024. LPAs observed required Licensing posters posted throughout the facility. LPAs reviewed drill logs which are conducted quarterly.

LPAs reviewed four (4) resident files, which contains signed admission agreements, physician's reports, identification sheets, consent forms, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPAs compared medications to those being given for two (2) residents and found no discrepancies. LPAs reviewed a total of two (2) staff record. Staff has training in medications, first aid/CPR, and other various areas.

No deficiencies being cited during today's inspection.

Exit interview conducted and report provided.
Laura MunozTELEPHONE: (916) 263-4743
Cheyenne RatajczakTELEPHONE: (916) 969-7879
DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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