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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002878
Report Date: 04/01/2022
Date Signed: 04/01/2022 11:39:24 AM


Document Has Been Signed on 04/01/2022 11:39 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:CARMEN ELDERLY CAREFACILITY NUMBER:
345002878
ADMINISTRATOR:ION, CARMENFACILITY TYPE:
740
ADDRESS:7548 ALMONDWOOD AVETELEPHONE:
(916) 673-6607
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:5CENSUS: 2DATE:
04/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administartor, Carmen IonTIME COMPLETED:
11:50 AM
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Licensing Program Analysts (LPAs) Michael Hood and Talwinder Bains met with applicant, Carmen Ion, to conduct a Pre- Licensing visit. This application is a change in ownership. This address is currently licensed as Carmen Elderly Care Facility #: 347005703. The facility has a fire clearance for five (5) non-ambulatory residents . Applicant holds a current administrator certificate (#6034379740 with expiration date 03/16/2023).

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are three (3) bedrooms and two (2) bathrooms for resident use. LPAs observed facility to be properly furnished, including appropriate bedding and lighting in bedrooms. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 112 degrees F. LPAs checked the kitchen area for the ability to prepare and store food. Knives and sharp objects found to be inaccessible for residents during visit. LPAs observed at least a 2-day perishable and 7-day nonperishable food supply at the facility. LPAs observed cleaning products and other toxins to be locked away. LPAs observed the area used for medication to be locked and inaccessible to residents. LPAs observed smoke detectors and carbon monoxide detectors at the care home are operational. Fire extinguishers are ready for emergency use. LPAs reviewed two (2) residents file and two (2) staff files.

Component III was completed. Application is pending and LPAs will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2022
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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