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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920116
Report Date: 07/23/2024
Date Signed: 07/23/2024 05:13:34 PM


Document Has Been Signed on 07/23/2024 05:13 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:LUXURY LIVING ASSISTED CAREFACILITY NUMBER:
345920116
ADMINISTRATOR:NAGY, GINGERFACILITY TYPE:
740
ADDRESS:7432 ANTELOPE RD.TELEPHONE:
(916) 402-1275
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 0DATE:
07/23/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator- Ginger NagyTIME COMPLETED:
05:20 PM
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On 07/23/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility announced to conduct a pre-licensing inspection utilizing the pre-inspection tool. LPA met with Administrator Ginger Nagy and explained the purpose of the visit.

LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to: three (3) residents shared bedrooms, two (2) bathrooms, kitchen, garage, storage area, and the patio. LPA observed resident bedrooms to have the proper furniture of comfortable bed, night stand, dresser, lamp and chair. LPA observed the facility to have a proper storage for medications, toxins and sharps which is locked and inaccessible. LPA observed facility to have ample supply of personal hygiene, linen, and non-perishable foods. LPA observed the exterior of the facility to be free of obstruction. The temperature inside the facility during the time of inspection was 76 degrees Fahrenheit. The hot water temperature was measured at 115.6 degrees Fahrenheit at the kitchen sink, which is within the required range of 105 to 120 degrees Fahrenheit. LPA observed fire extinguisher located in the hallway to be last serviced on 05/16/24. LPA observed smoke and carbon monoxide detectors to be operable. First aid kit is maintained and ready for use. LPA observed various required postings posted, including the Emergency Disaster Plan and Theft & Loss Policy. LPA observed some games/activities and an operating facility phone. LPA reviewed a sample resident file and found it to contain all the required forms.

LPA and Administrator completed the inspection tool and Comp III. Pre-Licensing completed and no deficiencies was observed. LPA provided Administrator a copy of LIC 311F. Administrator will inform LPA once they have their first resident.

LPA informed Applicant facility is not licensed until Applicant is informed by Centralized Application Bureau Analyst with a copy of facility license.

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: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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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