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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002946
Report Date: 09/04/2024
Date Signed: 09/04/2024 10:55:41 AM


Document Has Been Signed on 09/04/2024 10:55 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
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:
09/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff-Elainemarcia Anderson TIME COMPLETED:
11:00 AM
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On 09/04/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required- 1 Year inspection utilizing the inspection tool. LPA met with staff,Elainemarcia Anderson and explained the purpose of the visit. LPA requested for staff to notify Administrator of LPA's presence at the facility. Administrator was unable to meet at the facility and gave staff permission to assist LPA during today's visit.

Staff and LPA conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to: resident bedrooms, bathrooms, kitchen, common areas and the backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. The hot water temperature was measured at 113.5 degrees Fahrenheit in the bathroom sink which is within the required ranged of 105 to 120 degrees Fahrenheit. LPA observed fire detectors and carbon monoxide alarms to be operable. LPA observed the fire extinguisher located in living room last inspected on 08/28/24. LPA observed required Licensing posters posted throughout the facility.

LPA reviewed four (4) 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 two (2) personnel records and found them to be completed with required documents.

LPA requested for Administrator to email LPA a copy of the LIC308 and Liability Insurance.

No deficiencies being cited during today's inspection. Exit interview conducted and report provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
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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