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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002990
Report Date: 05/12/2023
Date Signed: 05/12/2023 04:02:25 PM


Document Has Been Signed on 05/12/2023 04:02 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 2DATE:
05/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Ana Docmanov, Co-Administrator- by phone TIME COMPLETED:
04:05 PM
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Licensing Program Analysts (LPA) Sabrina Calzada and Angela Hood arrived unannounced to conduct a case management inspection related to an incident report received on 5/10/23.

LPA's met with Danielle Smith and Maureen Brown, caregivers, and explained purpose of inspection. Caregiver Danielle attempted to contact Co-Administrator Ramona who was not able to be reached by phone but was able to contact Co-Administrator, Ana Maria Docmanov.

LPA's spoke to Ana and explained reason for inspection. Ana confirmed that resident (R1) was receiving hospice services at the time of her death on 5/9/23 and the hospice nurse completed the LIC624A that was faxed to the Department. LPA's stated how all information requested on the LIC624A needs to be completed, including if resident was receiving hospice services and location of death. Ana stated she understood and would re-submit the LIC624A for R1 and for resident (R2) who also passed this week, as the hospice nurse completed the second death report as well.

LPA's stated that the LIC624A needs to be reviewed/signed by an Administrator prior to submitting to the Department. Ana acknowledged. LPA's reviewed both resident files and confirmed residents were receiving hospice services. LPA observed copy of LIC624A for R2 in the file that had been faxed to Department.

Ana stated she has posted all required postings as stated in the Pre-Licensing report dated 2/28/23. LPA's observed all posting posted except for hand-washing posters in the bathroom. Caregiver agreed to post.

There are no deficiencies noted during today's inspection.

Exit interview with caregiver Danielle. Copy of report left at facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
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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