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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002924
Report Date: 12/20/2023
Date Signed: 12/20/2023 12:12:54 PM


Document Has Been Signed on 12/20/2023 12:12 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: 5DATE:
12/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Janeyn Kelly, Administrator TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to a recent fire clearance update. LPA met with Janeyn Kelly, Administrator, and explained purpose of inspection. Also present were Jhamil Espino, Licensee, Jacob Espino, caregiver, and Flocerfida Manalac, caregiver.

LPA received an updated fire clearance on 12/19/23 from the local fire department permitting residents to have a non-ambulatory status in rooms #1, 2,3, 4, 5 and 6. Additionally, (1) resident that is bedridden can be placed in room #3.

LPA and Administrator toured the facility and observed the recent modifications made in room #4 entailing a window being converted to a glass sliding door. (5) resident rooms are occupied and residents' ambulatory status meets the fire clearance. Currently room #2 is vacant but fully furnished.

LPA observed all residents to indicate they are doing well. LPA observed the facility to be clean, in good repair and Licensee to be preparing lunch in the kitchen.

LPA issued an updated copy of the facility license to reflect the recent changes approved by the local fire department.

Administrator provided LPA with an updated copy of the LIC610E (Emergency Disaster Plan for RCFE) which includes the new exit added to room #4. Administrator stated all resident rooms are approved exits also per the fire department. An updated copy of liability insurance was also obtained.

There are no deficiencies issued in this report.

Exit interview. Copy of report provided to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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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