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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700707
Report Date: 11/29/2022
Date Signed: 11/29/2022 03:40:09 PM


Document Has Been Signed on 11/29/2022 03:40 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:ELDERLY INN III, THEFACILITY NUMBER:
342700707
ADMINISTRATOR:BARAC, MARINELAFACILITY TYPE:
740
ADDRESS:8361 CANYON OAK DRIVETELEPHONE:
(916) 224-8880
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 5DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Marinela "Mari" Barac, Administrator TIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with staff, Ann Marie Thompson, who contacted Administrator, Marinela Barac by phone. LPA met with Administrator at approximately 1:50 pm, and explained purpose of inspection. LPA observed (3) residents in the common area and (2) residents in their rooms at the start of the inspection. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (2). Currently, there are (2) residents on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols, wore a surgical mask and was screened per Covid-19 precautionary measures upon entering the facility.

LPA and the Administrator toured the interior and exterior of the facility including the common areas, resident bedrooms (5), resident bathrooms (3), kitchen, staff room and laundry area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters posted. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps and locked medications in the kitchen. LPA observed toxins to be secured in the kitchen and laundry room. LPA observed the inside temperature to be 74*F. Fire extinguisher was last serviced 7/27/22. Discussed vaccination status of residents/staff, eligibility for boosters, and booster flyer provided. LPA observed multiple Covid posters throughout as well as other required postings. LPA observed (1) unlocked gate from the inside back patio. There are no bodies of water or a pool. LPA observed sufficient incontinent products and PPE on hand. LPA observed current RCFE Administrator Certificate #6016837740- exp 5/30/24 to be posted. Discussed PIN 22-28.1 issued 11/29/22 regarding visitation protocols. LPA observed a therapy dog who is regularly at the facility.

LPA obtained a copy of the current liability insurance and requested an updated copy of LIC500, LIC308 to be provided to the Department by 12/7/22. There are no deficiencies issued during today's inspection.
Exit interview. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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