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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002924
Report Date: 08/15/2023
Date Signed: 08/15/2023 02:25:26 PM


Document Has Been Signed on 08/15/2023 02:25 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:CITRUS PINES SENIOR LIVINGFACILITY NUMBER:
345002924
ADMINISTRATOR:KELLY, JANELYNFACILITY TYPE:
740
ADDRESS:8300 PATTON AVETELEPHONE:
(279) 529-2045
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 4DATE:
08/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Janelyn Kelly, Administrator and Jhamil Espino, LicenseeTIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection. LPA met with Jhamil Espino, Licensee, and explained purpose of inspection. Licensee contacted Administrator, Janelyn Kelly, who arrived at 11:00 am. Staff, Jacob Espino, was also present. LPA observed (4) residents in their rooms at the start of the inspection. There are (0) resident on hospice. The facility is licensed for (6) residents, (4) of whom may be non-ambulatory and (1) may be bedridden.

LPA and Administrator toured the interior and exterior of the facility including the common areas, (6) private resident rooms, (4) resident bathrooms, kitchen, laundry, and activity area. The staff reside in an adjoining area of the facility, separated by a locked door. LPA observed the facility to be clean, in good repair and odor-free. LPA observed each bathroom to have the necessary grab bars, non-skid flooring, paper towels, trash can with lid and 20-second hand-washing poster. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food. Sharps, toxins and medications are locked in the kitchen and additional locked toxins are in the laundry area. LPA observed sufficient PPE/incontinent supplies/emergency supplies and linens/towels/blankets. The inside temperature measured 72*F and hot water measured 115* in the kitchen. (1) smoke/monoxide alarm was tested and found to be working. Facility conducts quarterly emergency drills. Fire extinguisher was last serviced 3/16/23. There is (1) unlocked outside gate and a covered patio area with various gardens. LPA reviewed (2) of (4) resident files and found all required documentation. Medications were reviewed for (2) residents and are being given as ordered. Documentation is being done correctly. LPA reviewed (3) of (3) staff files and found them to contain current documentation, including First Aid/CPR certification. RCFE Administrator certificate is pending renewal- #6062074740- exp 1/19/24. LPA observed all required postings and the facility to have a complete Emergency Disaster Plan. Infection Control Plan is in the process of being updated. All staff are cleared/associated to the facility. An updated copy of liability insurance was obtained (exp 10/25/23). LPA was provided with an update made to SOS on 8/8/23. LPA requested facility email an updated copy of LIC308 and LIC500 to CCLD by 8/25/23. There are no citations issued. There is a technical advisory note being issued.
Exit interview. Copy of report provided to Administrators.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023
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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