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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002854
Report Date: 05/29/2024
Date Signed: 05/29/2024 10:13:03 AM


Document Has Been Signed on 05/29/2024 10:13 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:ALMOND GROVE ASSISTED LIVINGFACILITY NUMBER:
345002854
ADMINISTRATOR:PRICE, DARRELLFACILITY TYPE:
740
ADDRESS:6135 ALMOND AVENUETELEPHONE:
(916) 988-7506
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:78CENSUS: 58DATE:
05/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Assistant Director, Tosha DeviTIME COMPLETED:
10:15 AM
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Licensing Program Analysts (LPA) Talwinder Bains arrived at the facility unannounced on 05/29/24 to do case management visit . LPA met with Assistant Director,Tosha Devi and explained the purpose of the visit.

Department followed up on Incident Report sent by facility on 05/24/24 for date -05/24/24 regarding resident, R1 where R1 alleged that they fell in the transportation vehicle ( a non -medical ambulance) during a medical appointment on 05/24/24 when they returned around 1pm and refused to come out from vehicle . Facility Directors and staff members assessed R1 and suggested ER visit for possible injuries. R1 stated that they had some discomfort and pain on their left hip and right elbow. Facility Director contacted and spoke to the transportation company owner, they stated all transportation vehicles have a camera, and they have reviewed the footage and no fall occurred during this visit. Facility directors and staff contacted Alpha one ambulance to have the resident, R1 assessed for injuries, but R1 refused and signed AMA to be seen in the ER department. Staff checked R1 for any possible injuries, but none were observed. Facility notified R1s physician, responsible party, and long-term care ombudsman (LTCO) regarding this incident.

Department conducted interview with resident, R1 regarding this incident during today’s visit.

LPA requested documents related to this incident and facility will submit all documents by 05/31/24 by 5pm.

At this time, this case in under review and department will do follow up as needed.
No citations were issued per Title 22 Regulations.
Exit interview conducted and copy of the report left at facility.



SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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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