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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920026
Report Date: 07/17/2024
Date Signed: 07/17/2024 03:16:22 PM


Document Has Been Signed on 07/17/2024 03:16 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:EVERGREEN PALMS SENIOR CARE LLCFACILITY NUMBER:
345920026
ADMINISTRATOR:MALIUCOV, TATIANAFACILITY TYPE:
740
ADDRESS:7013 ROLLINGWOOD BLVDTELEPHONE:
(916) 205-2718
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 4DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator- Tatiana MaliucovTIME COMPLETED:
03:20 PM
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On 07/17/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a required 1 year annual inspection utilizing the care tool. LPA met with Administrator Tatiana Maliucov and explained the purpose of the visit. Administrator holds a current administrator certificate (#6066001740 with expiration date 03/01/2025).

LPA and Administrator toured the interior and exterior of the facility. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, storage area and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins, cleaning supplies and knives are locked and inaccessible to residents in care. The hot water temperature was measured in the kitchen at 117.5 degrees Fahrenheit, which is within the required range of 105 to 120. The temperature in the facility was 75 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. LPA observed medications to be locked and inaccessible to residents in care.

LPA reviewed four (4) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. LPA reviewed two (2) staff records. Staff has training in infection control, first aid/CPR, and other various areas of care provision.

LPA requested Administrator to email updated copies of the following by 07/24/24 to LPA

  • LIC308- Designation of Administrative Responsibility
  • Liability insurance
  • LIC500- Personnel Report

No deficiencies being cited during today's inspection.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
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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