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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700960
Report Date: 03/14/2024
Date Signed: 03/14/2024 10:33:08 AM


Document Has Been Signed on 03/14/2024 10:33 AM - 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:ECLIPSE HOME CAREFACILITY NUMBER:
342700960
ADMINISTRATOR:SAEGER, MAGDALENAFACILITY TYPE:
740
ADDRESS:9374 MANETTE WAYTELEPHONE:
(916) 904-6551
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 6DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Assistant Administrator,Mellissa Robinson TIME COMPLETED:
10:45 AM
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On 03/14/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Assistant Administrator (AA) , Mellissa Robinson and explained the purpose of the visit.

LPA and AA conducted a tour of the facility for inside and outside area. Areas toured included but not limited to the kitchen, dining room, residents bedrooms, bathrooms, common areas and backyard. LPA observed the facility to have sufficient food supplies for seven (7) day non-perishable and two (2) day perishable. LPA observed toxins, knives and centrally stored medications to be locked and inaccessible to residents in care. All required Licensing posters are present in common areas in the facility. Hot water temperature was measured at 119 degrees Fahrenheit at the kitchen sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 72 degrees. Fire extinguishers was last inspected on 01/23/24 and were ready for emergency use. Facility has a pool in the backyard which was found to be locked and properly secured during inspection. Facility has working smoke detectors and carbon monoxide alarm as required. Facility is conducting quarterly fire and disaster drills.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed residents (2) and staff files (2). Staff have current first aid and CPR training. Facility was clean. LPA reviewed medications of 2 residents comparing with physician orders and find no errors. Facility was using Centrally Stored Log for medications administration as required.

LPA requested a copy of the LIC500, LIC 308 and current liability insurance to be sent to LPA Bains by 03/31/24.

LPA completed the full care tool and no deficiencies were observed per Title 22, CCR Regulations.
Exit interview conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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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