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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920125
Report Date: 08/08/2024
Date Signed: 08/08/2024 03:57:24 PM


Document Has Been Signed on 08/08/2024 03:57 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:FOLSOM SENIOR CARE, LLCFACILITY NUMBER:
345920125
ADMINISTRATOR:LEPADAT, BRANDONFACILITY TYPE:
740
ADDRESS:260 BAURER CTTELEPHONE:
(916) 470-9993
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 5DATE:
08/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator- Brandon LepadatTIME COMPLETED:
04:00 PM
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On 08/08/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility announced to conduct a Pre- Licensing visit. LPA met with Administrator, Brandon Lepadat to conduct Pre- Licensing visit. This application is a change in ownership (CHOW). This address is currently licensed as Adina Home Care, #347002721. Administrator holds a current administrator certificate (#6060807740 with expiration date 01/07/25). The facility currently has five (5) resident during today's inspection. Facility has a fire clearance for six (6) non-ambulatory residents.

Administrator and LPA conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to resident bedrooms, bathrooms, kitchen, laundry room, garage, common areas and backyard. Resident bedrooms were properly furnished and maintained. Bathrooms were observed to be clean and sanitary. There is a pool in the backyard which is surrounded by a fence which is locked, the pool is inaccessible to residents. Facility food supply is in compliance with two (2) days of perishable and seven (7) days of non-perishable food items. Smoke and carbon monoxide detectors are operational. The Fire extinguisher was serviced on 04/15/24. Grab bars were present at the toilet and in the shower. All exits were unobstructed. All toxins, medications, and sharps were locked and stored away. Hot water temperature was observed to be 108.5 degrees Fahrenheit, which is within the required range of 105-120 degree. First aid kit found to be complete. Required Licensing posters are posted throughout the facility.

LPA reviewed one (1) resident file and one (1) staff. LPA provided administrator with a copy of LIC311F, records to be maintained at the facility.

Pre-licensing passed and Component III was completed. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. Exit interview conducted and a copy of this 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: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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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