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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701170
Report Date: 07/26/2023
Date Signed: 07/26/2023 12:11:25 PM


Document Has Been Signed on 07/26/2023 12:11 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:YOUNG AT HEART RCFE NO.4 INCFACILITY NUMBER:
342701170
ADMINISTRATOR:SISAYAN, LILLIANFACILITY TYPE:
740
ADDRESS:9012 COLOMBARD WAYTELEPHONE:
(916) 682-6080
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:6CENSUS: 6DATE:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Glenda MolinyaweTIME COMPLETED:
12:15 PM
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Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee made an unannounced visit to this facility to conduct an annual inspection on 07/26/2023 at 11:00 AM. LPAs met with Glenda Molinyawe and stated the purpose of today’s visit. LPAs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate. The facility is licensed for five non-ambulatory residents and has a hospice waiver for two. There are currently 6 residents who reside at this facility.

LPAs toured the facility with Glenda Molinyawe on 07/26/2023 at 12:00 PM.

LPAs reviewed 3 resident files and 3 staff files. All files were complete and maintained. LPA's reviewed 3 Medication Administration Records (MAR), and the MARs and medications were maintained and complete. The facility has a first aid kit. The fire extinguishers, smoke detectors and carbon detectors are in good repair. The last fire drill was completed on July 1, 2023. The facility has an adequate food supply, and the kitchen was sanitary and clean. All common areas, resident bathrooms, and resident bedrooms were furnished and in good repair. The facility water temperature measured at 105 degrees. The exterior of the facility is clear of debris, and the emergency exit gate was in good repair. Furthermore, all required postings were posted throughout the facility.

As a result, of this annual visit, there were no deficiencies cited. An exit interview was conducted, and a copy of this report was provided to facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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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