<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920066
Report Date: 09/24/2024
Date Signed: 09/24/2024 10:44:32 AM


Document Has Been Signed on 09/24/2024 10:44 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:VAN MOORE VILLAFACILITY NUMBER:
345920066
ADMINISTRATOR:NICULAI, SEFORAFACILITY TYPE:
740
ADDRESS:8924 VAN MOORE LANETELEPHONE:
(916) 218-8355
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 5DATE:
09/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Administrator, Sefora NiculaiTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Talwinder Bains arrived on 09/24/24 to conduct the annual inspection. LPA met with Administrator, Sefora Niculai and explained the purpose of today's visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed medications of two (2) residents comparing with physician orders and find no errors. LPA reviewed two (2) residents and two (2) staff files and found all required documents.

LPA and administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included residents rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher was ready for emergency use. Hot water temperature was observed to be 106 degrees F, which is within the regulation range of 105-120 degree. Inside temperature was 77-78 degree F. Facility was clean and well organized. All required postings were observed. Facility is conducting quarterly fire and disaster drill as required.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by 10/10/24.

No deficiencies were observed or cited per Title 22, CCR Regulations during this visit.
Exit interview conducted and copy of this report was provided to administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1