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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002990
Report Date: 12/20/2023
Date Signed: 12/20/2023 01:23:58 PM


Document Has Been Signed on 12/20/2023 01:23 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 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: 4DATE:
12/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Anamaria Docmanov, Co-Administrator TIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to a recent fire clearance update. LPA met with Star Smith, caregiver, and explained reason for the inspection. Also present was caregiver, Rachel Pitter. Administrator, Miodrag Docmanov, arrived at 12:45 pm. Anamaria Docmanov, Co-Administrator, arrived at 1:15 pm.

LPA received an updated fire clearance on 12/20/23 from the local fire department permitting (5) non-ambulatory residents to reside in rooms #1 through #5 and (1) bedridden resident to reside in room #6.

The most recent change was approving room #6 for a bedridden resident. The room was previously used for a staff room.

LPA and Administrator toured the facility and observed the recent modifications made including the installation of (2) fire doors and modifications to room #6, which included adding a fire door and exit door with a key.

Administrator to reprint the large facility sketch to reflect room #6 now authorized for a bedridden resident.

LPA to update the comments designating (5) rooms for non-ambulatory status and (1) room for bedridden in the Department's system and will email an updated copy of the facility license tomorrow.
Administrator to update LIC610E(Emergency Disaster Plan for RCFE) which includes the new exit added to room #6.

There are no deficiencies issued in this report.

Exit interview. Copy of report provided to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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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