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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700707
Report Date: 12/12/2023
Date Signed: 12/12/2023 03:22:51 PM


Document Has Been Signed on 12/12/2023 03:22 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: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: 3DATE:
12/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Marinela Barac, Administrator TIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Administrator, Marinela Barac. LPA observed (2) residents watching television in the common area and (1) resident in her room. LPA was advised there is currently (1) resident who remains hospitalized after being sent out a few days ago. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (2). Currently, there are (0) residents on hospice.

LPA and the Administrator toured the interior/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. LPA observed sufficient 2+day perishable, including fresh produce, and 7+day non-perishable supply of food. Sharps and toxins are locked in the kitchen and medications are secured nearby. Additional toxins are locked in the laundry room. Inside temperature measured 76*F and hot water measured 116*F in the kitchen. Fire extinguisher was last serviced 7/18/23 and smoke/monoxide alarms are in working order. There is sufficient linens/blankets/incontinent/PPE supplies, and a complete First Aid kit. Required postings are posted as well as the current Administrator Certificate #6016837740- exp 5/30/24. There is (1) unlocked gate from the inside back patio and no bodies of water. LPA reviewed the Infection Control Plan (LIC9282) and found it to be very comprehensive with additional pages for specific illnesses. LPA and Administrator discussed updated forms, including Personal Rights and LPA printed some out. LPA reviewed (2) resident files and found them to be organized and contain current documentation. Medications were reviewed for the same residents- orders match medications being administered and medications are being logged and PRN dosages given are being recorded. LPA reviewed (2) staff files and found them to also be organized, complete and current with documentation of required training. Administrator has current certification in First Aid/CPR and new staff will obtain it.
LPA obtained an updated copy of liability insurance. There are no deficiencies issued but there is a Technical Advisory Note. 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: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
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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