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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920073
Report Date: 09/20/2024
Date Signed: 09/20/2024 01:35:53 PM


Document Has Been Signed on 09/20/2024 01:35 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: 4DATE:
09/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Staff- Jamie MalloryTIME COMPLETED:
01:40 PM
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On 09/20/24, Licensing Program Analysts (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a case management visit. LPA met with Staff Jamie Mallory and explained the purpose of the visit. LPA spoke with Assistant Administrator, Juan Ramirez, via telephone call, who gave permission to have caregiver, Jamie Mallory, sign report.

The facility is currently licensed for six (6) non-ambulatory, hospice waiver of six (6). During today's visit, there are four (4) residents and 0 resident on hospice services.

During today's visit, LPA and Staff toured the interior of the facility to ensure the health and safety of residents in care. In areas toured, no immediate health and safety violation observed. LPA conducted interviews with residents and staff that were present at the facility.

As a result of today's inspection, no deficiencies cited at this time.

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: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
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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