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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700766
Report Date: 07/23/2024
Date Signed: 07/23/2024 12:49:52 PM


Document Has Been Signed on 07/23/2024 12:49 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:YELLOWTAIL HOME CAREFACILITY NUMBER:
342700766
ADMINISTRATOR:LUI, YINGFACILITY TYPE:
740
ADDRESS:8513 YELLOWTAIL WAYTELEPHONE:
(916) 725-2445
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 5DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Administrator- Ying Lui (Ruby)TIME COMPLETED:
12:55 PM
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On 07/23/24 Licesning Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required 1- year annual inspection utilizing the care tool. LPA met with Administrator Ying Lui (Ruby) and explained the purpose of the visit.

LPA and administrator conducted a tour of the interior and the exterior of the facility. Areas toured include but not limited to six (6) resident bedrooms, two (2) bathrooms, kitchen, laundry room, office and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and knives are locked and inaccessible to residents in care. The hot water temperature was measured in the kitchen sink at 107.9 degrees Fahrenheit, which is within the required range to 105 to 120 degrees Fahrenheit. The temperature in the facility was 75 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher was last serviced on 09/01/2023. LPA observed medications to be locked and inaccessible to residents in care.

LPA reviewed five (5) resident file. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, and resident's rights. LPA reviewed two (2) staff records. Staff has training in infection control, first aid/CPR, and other various areas of care provision.

LPA requested Administrator to send updated copies of the following by 07/26/24 to LPA
  • LIC308- Designation of Administrative Responsibility
  • Liability insurance
  • LIC500- Personnel Report


No deficiencies being cited during today's inspection.

Exit interview conducted and report provided
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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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