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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002857
Report Date: 03/07/2024
Date Signed: 03/07/2024 04:48:50 PM


Document Has Been Signed on 03/07/2024 04:48 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:ROBERT CREEK VILLAFACILITY NUMBER:
345002857
ADMINISTRATOR:KING, MARICARFACILITY TYPE:
740
ADDRESS:8134 ROBERT CREEK COURTTELEPHONE:
(925) 597-8181
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 5DATE:
03/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Maricar King, Administrator TIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Lourdes Nesperos, caregiver, and stated reason for the inspection. Administrator, Maricar King, arrived shortly. LPA observed (5) residents present. Currently, there is (1) resident on hospice. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (2).

LPA and the Administrator toured the interior and exterior of the facility including the common areas, (4) private resident bedrooms, (1) shared resident bedroom, (2.5) resident bathrooms, kitchen, and laundry 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 and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps in the kitchen. Medications are locked in a nearby cabinet and toxins are locked in a separate cabinet. Fire extinguisher was last serviced 7/31/23 and the smoke monoxide alarms to be working. Inside temperature measured 72*F and hot water measured 105*F in the kitchen. There are sufficient linens/towels/paper products/PPE. All required postings are in the common area. There is an activity person that visits three times weekly and is cleared/associated to the facility along with all other staff. LPA reviewed (3) resident binders and (2) staff binders and observed them to be complete, organized and contain current documentation. Staff training records were reviewed for (2) staff and all required training to be current. Documentation was submitted for Administrator re-certification in June 2023. Medications were reviewed for (2) resident- orders match medications being administered. There is (1) unlocked gate from the inside back patio. There are no bodies of water/pool. LPA reviewed/approved the Infection Control Plan. Emergency Disaster Plan is complete. Quarterly emergency drills are being conducted. LPA obtained an updated copy of current liability insurance, and requested LIC500 and LIC308 be provided to the Dept by 3/14/24. There are no deficiencies issued during today's inspection. Obtained updated land line number.

Exit interview with Administrator. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
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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