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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700707
Report Date: 01/16/2025
Date Signed: 01/16/2025 03:07:05 PM

Document Has Been Signed on 01/16/2025 03:07 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/
DIRECTOR:
BARAC, MARINELAFACILITY TYPE:
740
ADDRESS:8361 CANYON OAK DRIVETELEPHONE:
(916) 729-1866
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Marinela Barac, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual and met with Administrator, Marinela Barac. LPA observed (3) residents watching television in the common area and (1) resident in their room. 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, (5) resident bedrooms, (3) resident bathrooms, kitchen, staff room and laundry area. LPA observed the facility to be clean, in good repair and odor-free and 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. The inside temperature measured 75*F and hot water measured 120*F in the kitchen and in a resident bathroom. The fire extinguisher was last serviced 7/10/24, and all smoke/monoxide alarms are in working order. (Administrator to regularly check the hot water temperature and the fire alarms, at least twice/annually, to ensure the batteries are working). There are sufficient linens/blankets/incontinent/PPE supplies, and a complete First Aid kit. Required postings are in the common area as well as the current Administrator Certificate #700491740- exp 5/30/26. There are night-lights throughout, including next to the bathrooms. There is (1) unlocked gate from the inside back patio, covered seating and no bodies of water. LPA provided the flyer "Important Updates to Dementia Care and Miscellaneous Changes" effective 1/1/25 and discussed some changes in detail. LPA reviewed (2) resident files and (2) staff files- files were found to be organized and contain current documentation, including for required staff training. Medications were reviewed for (1) resident- orders match medications being administered and required documentation is maintained. LPA obtained an updated email address and requested an updated copy of liability insurance, LIC500 and LIC308 be provided by 1/21/25.

There are no deficiencies issued. Exit interview. Copy of report provided.
Maribeth SentyTELEPHONE: (916) 263-4813
Sabrina CalzadaTELEPHONE: (510) 829-2133
DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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