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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002866
Report Date: 02/21/2024
Date Signed: 02/21/2024 04:33:26 PM


Document Has Been Signed on 02/21/2024 04:33 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 VILLA IIFACILITY NUMBER:
345002866
ADMINISTRATOR:KING, MARICARFACILITY TYPE:
740
ADDRESS:8138 ROBERT CREEK COURTTELEPHONE:
(925) 567-8181
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 6DATE:
02/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Maricar King, Administrator TIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Maricar King, Administrator, and explained purpose of inspection. LPA observed (5) residents present and was advised (1) resident was temporarily out of the facility for medical treatment. 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 and medications in the kitchen, and locked toxins in the laundry area and another cabinet nearby. Fire extinguisher was last serviced 7/31/23 and the smoke monoxide alarms to be working. Inside temperature measured 74*F and hot water measured 108*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. Obtained updated land line and mobile contacts.

LPA reviewed (3) resident binders and (1) staff binder and observed them to be complete, organized and contain current documentation. Staff training records were reviewed for (1) staff and all required training to be current. Documentation was submitted for Administrator re-certification in June 2023. Medications were reviewed for (1) 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. LPA requested an updated copy of current liability insurance, LIC500 and LIC308. 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: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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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