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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002993
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:23:41 PM


Document Has Been Signed on 12/14/2023 02:23 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:MAHALOHA CARE LLCFACILITY NUMBER:
345002993
ADMINISTRATOR:RIVERA, GERALD JOHN G.FACILITY TYPE:
740
ADDRESS:8223 TWIN OAKS AVETELEPHONE:
(916) 910-6252
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 5DATE:
12/14/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Gerald Rivera, Administrator TIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a post-licensing inspection. LPA met with Sashana Barnett, caregiver, and explained purpose of inspection and then with Administrator, Gerald Rivera, who arrived at 12:45 pm. LPA observed (4) residents in the common area at the start of the inspection and the caregiver preparing for lunch to be served. (1) resident was in his room, The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (5).

LPA and the Administrator toured the interior/exterior of the facility including common areas, (1) shared resident bedroom, (3) private resident bedrooms, (1) vacant private resident bedroom, (2) bathrooms, kitchen, staff room, laundry area and outside patio. LPA observed the facility to be clean, in good repair and odor-free. Bathrooms have the necessary grab bars, non-skid flooring, paper towels and 20-second hand-washing poster. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, and locked sharps and toxins in the kitchen. Medications are secured nearby. Inside temperature measured 76*F and hot water temp measured 112* F in a resident bathroom. Hot water measured 128* in the kitchen- sign to be posted today- resident do not use this faucet. Fire extinguisher last serviced 1/3/23, and the smoke/monoxide alarms are working. LPA observed required postings- including the Ombudsman, See Something Say Something, LIC610E, facility sketch, Personal Rights, License, and Admin Certificate #6061379740- exp 12/26/23. Administrator will submit documentation for the renewal by 12/26/23. There is a gated/locked pool that is in the process of being filled with dirt to use the area as a patio. LPA checked (3) resident files and found them to be organized and contain current documentation. Facility paperwork matches new facility name. Medications were reviewed for (1) resident and matched orders. The facility uses a computerized system for medication management. LPA reviewed (3) current staff files. All staff have current First Aid/CPR on file. Staff to ensure the required (20) hours of continuing education is completed within each 12-month period. All staff is cleared and associated. Addendum to be added to Admission Agreement to update address for CCLD and add email/website for CCLD and LTCO. Facility to also update copy of personal rights to include most current copy, as posted. Infection Control Plan was complete. Emergency Disaster Plan needs to be finished. Copy of current liability insurance to be provided by 12/29/23. There are no deficiencies issued. Exit interview. Report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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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