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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920074
Report Date: 05/01/2024
Date Signed: 05/01/2024 01:25:39 PM


Document Has Been Signed on 05/01/2024 01:25 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 MATHISFACILITY NUMBER:
345920074
ADMINISTRATOR:FAAMAUSILI, CHRISFACILITY TYPE:
740
ADDRESS:7131 MATHIS COURTTELEPHONE:
(916) 678-0268
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 5DATE:
05/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator- Chris FaamausiliTIME COMPLETED:
01:30 PM
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On 05/01/24, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Pre- Licensing visit. LPA met with Administrator, Chris Faamausili and explained the purpose of the visit. This application is a change in ownership (CHOW). The address is currently licensed as Elizabeth Care Homes IV, Facility #345002840. Administrator holds a current administrator certificate (#6039698740 with expiration date 06/08/24 ). The facility currently has five (5) residents during today's inspection. Facility has a fire clearance for 6 non- ambulatory residents.

LPA and staff conducted a tour of the interior and exterior of the facility. Areas toured include but are not limited to: two (2) private resident bedrooms and two (2) shared resident bedrooms, bathrooms, kitchen, dining room, laundry room, and common areas. Bedrooms have appropriate furnishings. Grab bars were present in the bathroom. The facility has a food supply of, 2 days of perishable and 7 days of non-perishable food items. Smoke detectors and carbon monoxide detectors are present and operational. The Fire extinguisher was last serviced 09/15/23. All exits were unobstructed. All toxins, medications, and sharps were locked and inaccessible to residents in care. Facility's temperature was 75 degrees during todays inspection. Hot water temperature was observed to be 112.5 degrees Fahrenheit, which is within the regulation range of 105-120 degree. First aid kit present and maintained.LPA reviewed one (1) resident and one (1) staff file and found that all required paperwork was present. LPA did provide facility with LIC311F.

Component III was waived as the current administrator has been administrator for other RCFEs licensed by CCLD.

LPA will forward findings to the Centralized Application Bureau (CAB) that facility met all the pre-licensing components. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection. A copy of this report was left at the facility. Exit interview conducted.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
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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