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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920075
Report Date: 07/16/2024
Date Signed: 07/16/2024 12:12:35 PM


Document Has Been Signed on 07/16/2024 12:12 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:PURE CARE HOMEFACILITY NUMBER:
345920075
ADMINISTRATOR:MESLOUB, SID ALIFACILITY TYPE:
740
ADDRESS:6355 PERRIN WAYTELEPHONE:
(916) 254-1412
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
07/16/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Sid MesloubTIME COMPLETED:
11:30 AM
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7/16/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a post licensing inspection. LPA met with Caregivers, and explained the purpose of the visit. Administrator then arrived shortly after tour was conducted.

Today's census is four residents with one resident on hospice services, facility is licensed for six non-ambulatory, hospice waiver of six.

LPA conducted a tour of the interior of the facility. Areas toured included but not limited to: kitchen, bathroom, residents bedrooms and the common areas. LPA observed four residents in care with two caregivers. LPA observed medications and sharps to be locked and inaccessible to residents in care.

LPA informed Administrator that all staff are to have the required initial and annual training as per ยง1569.625 Staff training; legislative findings; contents. LPA and Administrator discussed first aid training for all staff and at least one staff per shift with cardiopulmonary resuscitation (CPR) certification. LPA and Administrator discussed that all residents file are to have physician orders for each medication. LPA and Administrator discussed keeping communications and charting notes with hospice/home health agencies regarding residents condition.

File review conducted for residents and staff. At this time, no deficiencies cited.

Exit interview conducted and a copy of the report was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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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