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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002993
Report Date: 03/15/2024
Date Signed: 03/15/2024 11:44:02 AM


Document Has Been Signed on 03/15/2024 11:44 AM - 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) 910-9652
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 4DATE:
03/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Gerald Rivera, Administrator TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Sabrina Calzada and IB Investigator Nathan Gonzalez arrived unannounced to conduct an annual inspection. LPA met with Sashana Barnett, caregiver, and explained purpose of inspection and then with Administrator, Gerald Rivera, who arrived at 10:30 am. LPA observed (4) residents in the common area eating breakfast at the start of the inspection and (1) resident was in his room, The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (5). Currently no residents are on hospice.

LPA and the Administrator toured the interior/exterior of the facility including common areas, (1) shared resident bedroom, (4) private resident bedrooms, (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. Fire extinguisher last serviced 1/8/24 and smoke/monoxide alarms are working. Inside temperature measured 72*F and hot water temp measured 120* F in the kitchen and in a resident bathroom. There are sufficient linens/towels/blankets and PPE/paper products. Administrator Certificate #6061379740 is pending renewal. There is a gated/locked pool in the process of being converted to an extended patio. Patio seating is covered. First aid kit is complete.

LPA checked (3) resident files and found them to be organized and contain current documentation.
Medications were reviewed for (2) residents and matched orders on file. The facility uses a computerized system for medication management including medication documentation. LPA reviewed (3) current staff files. All staff is cleared/associated and has current First Aid/CPR on file. Staff has completed required annual training.

Infection Control Plan was reviewed/approved. Emergency Disaster Plan is complete. Copy of current liability insurance on file. Copy of LIC308 and LIC500 to be provided by 3/22/24. There are no deficiencies issued. There are (2) Technical Advisory Notes issued today.
Exit interview. Report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024
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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