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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002823
Report Date: 10/30/2023
Date Signed: 10/30/2023 04:25:09 PM


Document Has Been Signed on 10/30/2023 04:25 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:WHOLESOME ELDERLY ON KIFISIAFACILITY NUMBER:
345002823
ADMINISTRATOR:FAAMAUSILI,CHRISFACILITY TYPE:
740
ADDRESS:6024 KIFISIA WAYTELEPHONE:
(916) 678-0268
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Geneva Campbell, CaregiverTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 10/30/23 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA spoke with Assistant Administrator, Juan Ramirez, via telephone call, who gave permission to have caregiver, Geneva Campbell, sign report.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are five (5) bedrooms and two (2) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. Bathrooms were in sanitary condition and properly maintained.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors to be operational in the care home. LPA checked medication storage and found medication to be locked away and inaccessible to the residents. LPA reviewed three (3) resident files and two (2) staff files. LPA requested a copy of the facility's certificate of liability insurance.

As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Section 87203 regarding fire extinguishers not being serviced and carbon monoxide detectors not being operational, Section 87303(e)(2) for hot water temperature being observed at 123 degrees F, and 87303(a) for disrepair of the facility. Deficiencies are listed on 809-D. An immediate civil penalty per Health and Safety Code ยง 1548 in the amount of $500 for the date of 10/30/2023 is assessed for a violation that the department determines was a fire clearance violation.

Exit interview was conducted with Licensee. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 10/30/2023 04:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: WHOLESOME ELDERLY ON KIFISIA
FACILITY NUMBER: 345002823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the facility did not ensure that hot water temperatures were maintained not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C) when hot water was measured to be 123 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Facility will decrease hot water temperatures to be maintained not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C) by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 10/30/2023 04:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: WHOLESOME ELDERLY ON KIFISIA
FACILITY NUMBER: 345002823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, facility carpets were stained, trash compacter was in disrepair, gate in backyard was in disrepair, ice machine was in disrepair, and locks on drawers were in disrepair, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Facility will repair carpets, repair or remove trash compacter, repair backyard gate, repair locks on drawers, and either repair ice machine or provide another method for the facility to have ice. Repairs will be completed by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/30/2023 04:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: WHOLESOME ELDERLY ON KIFISIA
FACILITY NUMBER: 345002823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the facility did not ensure that fire extinguishers were serviced and carbon monoxide detectors were operational, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee will service fire extinguishers and install carbon monoxide detectors. Licensee will submit proof to LPA be POC due date. An immediate civil penalty in the amount of $500 was assessed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4