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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920073
Report Date: 07/24/2024
Date Signed: 07/24/2024 02:49:40 PM


Document Has Been Signed on 07/24/2024 02:49 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:WHOLESOME ELDERLY ON MAR VISTAFACILITY NUMBER:
345920073
ADMINISTRATOR:FAAMAUSILI, CHRISFACILITY TYPE:
740
ADDRESS:7401 MAR VISTA WAYTELEPHONE:
(916) 678-0268
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 5DATE:
07/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator- Noel EstilloreTIME COMPLETED:
03:00 PM
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On 07/24/24 Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Cheyenne Ratajczak and Grahamn Gunby arrived at the facility unannounced to conduct a Case Management Incident visit. LPM and LPAs met with Administrator Noel Estillore, and explained the purpose of the visit.

The purpose of the visit is to gather additional information regarding an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 07/11/2024. The report indicates that Resident #1 (R1) had called the police department and alledged that they are being abused.



During today’s visit LPAs obtained a copy of R1s file and conducted interviews with staff and residents. Interviews with staff indicated that R1s recollection of the events have changed a couple of times. LPM and LPAs were unable to interview R1 due to R1 not currenly being in the facility.

At this time, deficiencies are not being cited.



An exit interview conducted and 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: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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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