342700763-2-8-2021-27-AS-SCAA-BY338E-20210208170124

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700763
Report Date: 02/08/2021
Date Signed: 02/08/2021 05:02:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	A-1 ELDERLY CARE		FACILITY NUMBER:	342700763
ADMINISTRATOR:	TIF, ROBERT		FACILITY TYPE:	740
ADDRESS:	5210 ROBERTSON AVE		TELEPHONE:	(916) 996-4763
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 0	DATE:	02/08/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Robert Tif, Administrator		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Sabrina Calzada contacted Robert Tif, Administrator, for a scheduled pre-licensing inspection via tele-visit on 2/8/2021, due to current Covid-19 precautionary measures in place. This is a change in ownership; however, there are no residents currently at the facility. LPA and Administrator toured the interior and exterior of the facility including the common areas, resident bedrooms (4), bathrooms kitchen, laundry area, and staff room. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting throughout. LPA observed all resident bedrooms to be complete with required furniture, and the bathrooms to have the necessary grab bars and non-skid flooring in the bathrooms, as well as trash cans with lids. LPA observed sufficient 7+day non-perishable supply of food and sufficient dishes, flatware and cooking pans. LPA observed sharps and toxins to be locked in the kitchen and medications to be locked in a cabinet nearby and additional toxins to be locked in the laundry area. LPA observed the smoke/monoxide alarms to be in working order, and the fire extinguisher to have been last serviced 6/29//2020. LPA observed sufficient towels, linens and hygiene supplies and a complete first aid kit on hand. Administrator to obtain a copy of a current First Aid Manual. LPA observed the Administrator to measure the hot water temperature with a thermometer in a resident bathroom and kitchen at 111* F. Resident/Staff binders to be put together with required paperwork. LPA observed board games and books on site. LPA observed (1) unlocked exit gate and ramps on one side and front of the facility and all exit doors to have alarms. There and no pools/bodies of water present. LPA observed the following posted at facility: Resident Personal Rights, a completed Emergency Disaster Plan for RCFE (LIC610E), See Something Say Something poster, Ombudsman poster, Facility sketch with evacuation route, Theft and Loss Policy, and Rights of Resident/Family Councils, Non-Discrimination notice, Administrator's RCFE Administrator Certification-#6047124740- exp 2/9/2022. To post: House Rules. cont on 809C...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: A-1 ELDERLY CARE	FACILITY NUMBER: 342700763
	VISIT DATE: 02/08/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed PPE, paper products and cleaning supplies on hand.

Comp III was conducted during today's inspection. ** Also, Covid-19 precautionary measures were discussed and resource materials were e-mailed following today's tele-visit. **

Pre-licensing is complete and this facility has no deficiencies. LPA to notify analyst in application unit of inspection being conducted.

An exit interview was conducted with Administrator during today's tele-visit, and a copy of this report will be provided to the facility via e-mail. Administrator agree to sign and return a copy of the report to CCL and to keep a copy for the facility records.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2