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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002921
Report Date: 10/09/2023
Date Signed: 10/09/2023 02:14:33 PM


Document Has Been Signed on 10/09/2023 02:14 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:GRANNY'S COTTAGE LLCFACILITY NUMBER:
345002921
ADMINISTRATOR:BANCU, ADALBERTHFACILITY TYPE:
740
ADDRESS:7717 DEANTON CT.TELEPHONE:
(916) 606-9670
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 5DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Adalberth "Albert" Bancu, Administrator TIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with caregivers, Floarea Bancu and Sabinel Bancu, and explained purpose of inspection. Albert Bancu, Administrator, arrived at 11:30 am.The facility is currently licensed for (6) non-ambulatory residents and has a hospice waiver for (6). Currently, there are (4) residents on hospice.

LPA and Administrator toured the interior and exterior of the facility including the common areas, (2) shared resident bedrooms, (2) private resident bedrooms, (2) resident bathrooms, (1) staff/visitor bathroom, kitchen, staff room and garage/locked laundry area. LPA observed the facility to be clean, in good repair and odor-free. All bathrooms 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, including fresh produce. Sharps are locked in the kitchen, medications are secured nearby and toxins are locked in the laundry/garage area. Inside temperature measured 77*F. Fire extinguisher was last serviced 6/19/23 and smoke/monoxide alarms in working order. Hot water temperature measured 118*F in the kitchen and 120*F in a resident bathroom. First Aid kit is complete. There are sufficient paper/incontinent products, PPE and linens/blankets . All required postings are posted. All doors have exit alarms and there is (1) unlocked gate in the backyard. There is covered patio seating.

LPA reviewed and approved the Infection Control Plan (LIC9282) updated in May 2023. LPA reviewed (3) staff files- all staff have current First Aid/CPR training and have completed the required annual training. LPA reviewed (2) resident files and found them to be organized and contain current paperwork. Medication orders were compared with medications being administered for (1) resident, and there were no discrepancies found. All medication is being documented correctly on the Medication Administration Record (MAR) and the LIC622. LPA requested an updated copy of LIC308 and LIC500 be provided to the Department by 10/16/23. There were no deficiencies observed.Exit interview. Copy of report given to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023
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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