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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002951
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:27:39 PM


Document Has Been Signed on 10/05/2023 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:LIVING WATER CARE HOME INC, THEFACILITY NUMBER:
345002951
ADMINISTRATOR:PRANOTO, HERLINAFACILITY TYPE:
740
ADDRESS:7800 CLAYPOOL WAYTELEPHONE:
(279) 529-2233
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 3DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Herlina Pranato, Administrator TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Herlina Pranato, Administrator and Gabrielle "Gaby" Hanggono, caregiver, and explained purpose of inspection. Also present was Grace Gunawan, owner,who was present in the beginning.
LPA observed (3) residents present. Currently, there are (0) residents on hospice.

LPA and the Administrator toured the interior and exterior of the facility including the common areas, resident bedrooms (5), resident bathrooms (2), kitchen, staff room and laundry/garage area. LPA observed the facility to be clean, in good repair and odor-free. LPA observed all but bathroom to have the necessary grab bars and all bathrooms to have non-skid flooring, paper towels and hand-washing posters. The bathroom with missing grab bars in the shower is currently vacant. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps in the kitchen, locked toxins in the laundry area and medications to be secured nearby. LPA observed the inside temperature to be 74*F. Fire extinguisher was last serviced 3/27/23 and the smoke-monoxide alarms to be working. Hot water measured 108* in the kitchen and there is a complete First Aid kit on site. LPA reviewed (3) resident binders and found them to be complete, organized and contain current documentation. LPA reviewed ordered medications to those being administered for(1) resident and found no errors- facility maintains current medication documentation. Administrator has a bag of medication not currently being used for (R1) -will obtain a discontinuance order and properly destruct the meds. Staff training records were reviewed for (4) staff - all required training was recently completed through an approved on-line vendor. First Aid/CPR is current. Administrator certificate #6063770740- exp 11/13/24 is posted as well as other required postings. LPA reviewed/approved the facility's Infection Control Plan, submitted in February 2023 and found it to be complete. There is covered outside seating and (1) exit gate is unlocked from the inside. LPA printed and reviewed the LIC624/A reports during today's inspection. LPA requested an updated copy of current liability insurance, LIC500 and LIC308.
There are no deficiencies issued during today's inspection but there are (2) advisory notes issued.
Exit interview with Administrator. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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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