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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002946
Report Date: 10/11/2023
Date Signed: 10/11/2023 03:27:27 PM


Document Has Been Signed on 10/11/2023 03:27 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 CREST CARE HOME 2FACILITY NUMBER:
345002946
ADMINISTRATOR:SOUMAHORO, MUAMOUDOUFACILITY TYPE:
740
ADDRESS:6813 MARINVALE DRTELEPHONE:
(916) 904-0027
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 6DATE:
10/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Staff: Abietuwanjanet EdopolorTIME COMPLETED:
04:00 PM
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On 10/11/2023 at 2:05 PM, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with staff, Abietuwanjanet Edopolor, and explained purpose of the visit. LPA requested for staff to notify administrator of LPA's presence at the facility.

At 2:20 PM, LPA and staff toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, garage, laundry room, and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. Toxic and cleaning supplies locked and is inaccessible to residents in care. The hot water temperature was measured at 113 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. LPA observed the fire extinguisher located in living room. LPA observed medications to be locked and inaccessible to residents in care. LPA observed required Licensing posters posted throughout the facility.
At 2:40 PM, LPA reviewed a total of two (2) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for two (2) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of two (2) staff record. .

No deficiencies being cited during today's inspection.

Exit interview conducted and report provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
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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