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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002840
Report Date: 10/18/2023
Date Signed: 10/18/2023 03:30:26 PM


Document Has Been Signed on 10/18/2023 03:30 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:ELIZABETH CARE HOMES IVFACILITY NUMBER:
345002840
ADMINISTRATOR:CHRIS FAAMAUSILIFACILITY TYPE:
740
ADDRESS:7131 MATHIS COURTTELEPHONE:
(650) 248-1108
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 2DATE:
10/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Juan Ramirez, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Juan Ramirez, Administrator and caregiver and explained purpose of inspection. Also present was Shain Swogger, family member of the Administrator. LPA observed (2) residents in the common area during the inspection. Currently, there are (0) residents on hospice. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (2). There is a pending change in ownership. LPA to return once requested to conduct a pre-licensing inspection.

LPA and the Administrator toured the interior and exterior of the facility including the common areas, (2) shared resident bedrooms, (2) private resident bedrooms, (2) bathrooms, kitchen, staff rooms and laundry/garage 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 - will post 20-second hand-washing poster. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps and medications in the kitchen and observed toxins to be secured nearby. Inside temperature measured 73*F and hot water temp measured 108* F in the kitchen. Fire extinguisher last serviced 9/15/23 and the smoke/monoxide alarms are working. Additionally, all repairs have been made following a fire inspection in September 2023 for the pending License. Specifically, the fire extinguisher is now attached and a latch was added to the door frame for room #4 and the weather strip has been replaced on the exit door to the patio. The front common area will be used as an office and lounge/quiet area for residents. The medications will be locked in an area nearby. LPA observed various items posted, including the Ombudsman poster, See Something Say Something poster, LIC610E, facility sketch, Personal Rights, and Asst. Admin Certificate # 6059447740- exp 9/26/2023 (was renewed). Administrator Certificate to be posted for Chris Faamausili, Administrator of record, and also for Juan Martinez, when received by the Department. LPA checked both resident files and found them to contain current and complete documentation. LPA also compared medication orders for both residents to medications being administered and found no errors. There is a pharmacy change pending for both residents. Administrator to place sanitizer at the front entrance and post visiting hours.
LPA requested an updated copy of LIC500 and the LIC308. There were no deficiencies observed.
Exit interview. Copy of report left with Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023
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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