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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002990
Report Date: 02/28/2023
Date Signed: 02/28/2023 04:59:58 PM


Document Has Been Signed on 02/28/2023 04:59 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:CITRUS HEIGHTS SENIOR LIVINGFACILITY NUMBER:
345002990
ADMINISTRATOR:DOCMANOV, MIODRAGFACILITY TYPE:
740
ADDRESS:8440 EDGECLIFF CTTELEPHONE:
(916) 678-2908
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 3DATE:
02/28/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Ramona Iordche, Co-Administrator and Ana Docmanov, Co-AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a pre-licensing inspection for a change in ownership. LPA met with Shantal Bernard, caregiver, who contacted Ana Docmanov, Co-Administrator, by phone. LPA spoke to Ana who indicated she is currently out of town and advised LPA that Co-Administrator, Ramona Iordche, would be able to meet LPA. Ramona arrived at approximately 3:30 pm. LPA observed (3) residents to be resting in their rooms The facility is currently licensed for (6) non-ambulatory residents and has a hospice waiver for (3). Currently, there is (1) resident on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols. LPA was screened per Covid-19 precautionary measures upon entering the facility, and wore a surgical mask.

LPA and caregiver toured the interior and exterior of the facility including the common areas, resident bedrooms (6), resident bathrooms, kitchen, staff rooms, pantry and laundry area. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels, trash cans with a lid- Administrator to post 20-second hand-washing posters at each bathroom/kitchen sink. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, locked sharps and medications in the kitchen and locked toxins in the laundry area. LPA observed the inside temperature to be 74*F. Fire extinguisher was last serviced on 11/17/2022. LPA observed the smoke/monoxide alarms to be working and sufficient PPE supplies, paper products and linens/blankets/towels. LPA observed games, movies and books. LPA observed alarms on all exit doors and (2) exterior gates to be unlocked from the inside. LPA observed various Covid/other postings to be visible- Licensee/Administrators to ensure that all required postings are re-posted after recent painting of walls. LPA reviewed (3) resident and staff file and observed them to be organized and contain current documentation. LPA and Ramona completed all domains of the tool.

Component III was reviewed during today’s inspection- Co-Administrator, Ana, was present vis tele-visit. It appears the facility is in substantial compliance and there are no deficiencies being noted today.

Exit interview done. Copy of report provided to Co- Administrator and application unit to be notified.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2023
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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