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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002993
Report Date: 04/21/2023
Date Signed: 04/21/2023 03:12:36 PM


Document Has Been Signed on 04/21/2023 03:12 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:MAHALOHA CARE LLCFACILITY NUMBER:
345002993
ADMINISTRATOR:RIVERA, GERALD JOHN G.FACILITY TYPE:
740
ADDRESS:8223 TWIN OAKS AVETELEPHONE:
(808) 475-4960
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 5DATE:
04/21/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Gerald Rivera, Admin and Sashana Barnett, caregiver TIME COMPLETED:
03:15 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 Sashana Barnett, caregiver, and explained purpose of inspection. The Administrator was only able to virtually attend the Comp III portion of the inspection due to an appointment. LPA observed (3) residents to be enjoying music in the common area and (1) resident to be resting in his room at the start of the inspection. One (1) resident returned to the facility towards the end of the inspection. The facility is currently licensed for (6) non-ambulatory residents and has a hospice waiver for (5) residents. Currently, there are (0) residents on hospice.

LPA and caregiver toured the interior and exterior of the facility including the common areas, (3) private resident bedrooms, (1) shared resident bedroom (2) resident bathrooms, kitchen, staff room and outside 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 and hand-washing posters. Administrator to ensure there is hand soap available at all times in the bathroom. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, locked sharps and toxins in the kitchen and locked toxins in the outside laundry area. LPA observed the inside temperature to be 70*F. Fire extinguisher was last serviced on 1/3/23 and all doors and windows have alarms on them. There is a pool that is fenced and locked and a covered patio area able to accommodate a table and chairs. LPA observed a new First Aid kit and PPE supplies. (2) smoke/monoxide alarms sounded when tested- batteries to be checked in (2) other units. Facility has emergency supply kits on site. LPA discussed how new resident paperwork to be completed upon ownership change. LPA reviewed (1) resident file and (1) staff file and found it to be organized and contain required paperwork. LPA observed various required postings- Administrator to ensure that Theft & Loss Policy, blank admission agreement and visitation policy is also posted. Water temperature measured at 135*F/140*F at 1:15 pm in one resident bathroom kitchen. The hot water setting on the water heater was lowered during the inspection- Administrator to send photos showing the water temperature has dropped to between 105*-120*F, per regulation by tomorrow, 4/22/23. A Technical Advisory Notice is being issued. Component III was reviewed during today’s inspection- Administrator attended virtually. LPA to notify the applications unit the facility is in substantial compliance once documentation of updated water temperature has been received. Exit interview done with caregiver who is authorized by Administrator to sign today's report. Copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
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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