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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700877
Report Date: 10/04/2023
Date Signed: 10/04/2023 04:45:10 PM


Document Has Been Signed on 10/04/2023 04:45 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:ROBERT CREEK VILLA IFACILITY NUMBER:
342700877
ADMINISTRATOR:SBINGU, ADINAFACILITY TYPE:
740
ADDRESS:8135 ROBERT CREEK VILLA COURTTELEPHONE:
(916) 745-4230
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 6DATE:
10/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Adina Sbingu, AdministratorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Mariana "Mimi" Musca, caregiver, and stated reason for the inspection. Mariana contacted the Administrator, Adina, by phone, who arrived at approximately 2:00 pm. LPA was advised that (2) of (6) residents were out of the community; (1) returned during the inspection. (1) resident is currently under hospice care. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (3).

LPA and Administrator toured the interior and exterior of the facility including the common areas, (6) resident bedrooms with private bath, (2) full bathrooms, kitchen, staff rooms and garage/locked 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 and 7+day non-perishable supply of food, and locked sharps, toxins and medications in the kitchen. There are locked medications in the refrigerator. LPA observed the inside temperature to be 79*F. Fire extinguisher was last serviced 8/21/23. Hot water temperature measured 110*F in the kitchen. First Aid kit on site as well as sufficient paper products, including PPE. All required postings are posted.

LPA reviewed the Infection Control Plan (LIC9282) and additional pages, that were last updated on 5/23/23 and found it to be very comprehensive. LPA observed (1) unlocked gate from the inside back patio with covered patio seating. There are no pools or bodies of water. LPA observed copy of RCFE Administrator certificate # 6004705740- exp 11/2/23- renewal documentation to be submitted this month. LPA reviewed (3) resident files and found them to contain current/complete documentation. Meds were reviewed for (1) resident and orders matched meds being administered. Documentation is current also. LPA reviewed all staff files - all staff have current First Aid/CPR certification and have completed recent annual training for (40) hours. LPA requested an updated copy of LIC500, LIC308 and current liability insurance today by 10/11/23.
There are no deficiencies issued during today's inspection. Exit interview with Administrator. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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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