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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002863
Report Date: 02/16/2024
Date Signed: 02/16/2024 01:21:43 PM


Document Has Been Signed on 02/16/2024 01:21 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:HOLY FAMILY SENIOR LIVINGFACILITY NUMBER:
345002863
ADMINISTRATOR:FERDINAND GORGONAFACILITY TYPE:
740
ADDRESS:8272 OAK AVETELEPHONE:
(916) 633-6699
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 4DATE:
02/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Ferdinand Gorgona, Administrator TIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Princess Polvos, caregiver, and explained purpose of inspection. LPA met with the Administrator, Ferdinand Gogona, who arrived at the facility shortly. LPA observed (4) residents present. Currently, there are (2) residents on hospice. The facility has a hospice waiver for (6).

LPA and the Administrator toured the interior and exterior of the facility including the common areas, resident bedrooms (4), resident bathrooms, kitchen, staff room,laundry and 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 and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps and toxins in the kitchen. There are additional locked toxins in the laundry room, and medications are secured in a separate cabinet. The inside temperature to be 74*F. Fire extinguisher was last serviced 1/29/24, and the smoke monoxide alarms are working. There is a complete First Aid kit and sufficient PPE, linens, towels. Hot water measured 116*F in the kitchen. There is one unlocked exit in the backyard and patio seating with a small garden. (2) resident files were reviewed and found to be organized and contain current documentation. Residents are placed in resident rooms that are in compliance with the fire clearance. Medications were reviewed for (1) resident and orders matched medications being administered. Staffing files were reviewed. Staff has current First Aid/CPR certification and the Administrator certificate #6067246740- exp 8/14/25. Staff have completed much training since starting in Jan 2024- hospice training is in the process.

LPA provided Infection Control Plan to complete/submit by 2/23/24, along with LIC500 and LIC308. Copy obtained of current liability insurance.

There are no deficiencies issued during today's inspection. 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: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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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