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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700763
Report Date: 01/25/2023
Date Signed: 01/25/2023 12:34:16 PM


Document Has Been Signed on 01/25/2023 12:34 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:A-1 ELDERLY CAREFACILITY NUMBER:
342700763
ADMINISTRATOR:TIF, ROBERTFACILITY TYPE:
740
ADDRESS:5210 ROBERTSON AVETELEPHONE:
(916) 996-4763
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
01/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Robert TifTIME COMPLETED:
10:55 AM
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Licensing Program Analysts (LPA) Kevin Mknelly and Ryan Ayers arrived at the facility unannounced on 1/25/23 to conduct a Annual Inspection utilizing the infection control domain. LPA met with Administrator and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 the department protocols. LPAs completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured LPAs observed and discussed a smoke alarm that has recently malfunctioned a replacement will be installed today. Additionally LPA discussed with administrator how and when door stops may be used and that it cannot be placed permanently. Administrator will notify LPA when system is operational no sooner that 1/26/23
LPAs and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time. LPA advised increased screening and documentation for visitors, employees and residents.
LPA Mknelly conducted 2 resident file reviews and advised regarding incontinence care plans and medications managed by residents.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
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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