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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000878
Report Date: 07/27/2023
Date Signed: 07/27/2023 01:26:50 PM


Document Has Been Signed on 07/27/2023 01:26 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:PHYLLIS' CARE HOMEFACILITY NUMBER:
347000878
ADMINISTRATOR:JAR, ALINAFACILITY TYPE:
740
ADDRESS:6924 LE HAVRE WAYTELEPHONE:
(916) 722-0824
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 4DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Administrator: Alina JarTIME COMPLETED:
01:40 PM
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On 07/27/2023 at 12:24 PM, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Licensee, Alina Jar, and explained the purpose of the visit.

At 12:30 PM, LPA and Licensee toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, garage and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. Toxic and cleaning supplies locked and is inaccessible to residents in care. LPA observed pool in the backyard is locked and inaccessible to residents in care. The hot water temperature was measured in the kitchen at 107 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher was last serviced on 10/17/2022. LPA observed medications to be locked and inaccessible to residents in care.

At 12:40 PM, LPA reviewed a total of four (4) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for four (4) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of two (2) staff record. Staff has training in infection control, first aid and CPR, and other various areas of care provision.

No deficiencies being cited during today's inspection.

Exit interview conducted and report provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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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