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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000878
Report Date: 07/01/2024
Date Signed: 07/01/2024 10:50:44 AM

Document Has Been Signed on 07/01/2024 10:50 AM - 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/
DIRECTOR:
JAR, ALINAFACILITY TYPE:
740
ADDRESS:6924 LE HAVRE WAYTELEPHONE:
(916) 722-0824
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 6CENSUS: 4DATE:
07/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator- Alina JarTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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On 07/01/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required 1 year annual inspection. LPA met with Administrator Alina Jar and explained the purpose of the visit.

LPA and Administrator toured the interior and exterior. 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 seven (7) days and perishable foods for a minimum of two (2) days. Toxic and cleaning supplies locked and inaccessible to residents in care. The hot water temperature was measured in the kitchen at 118.8 degrees Fahrenheit. The temperature in the facility was 78 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 10/17/2023. LPA observed medications to be locked and inaccessible to residents in care.

LPA reviewed four (4) resident file and two (2) staff files all files contained the required documents.

LPA requested Administrator to send updated copies of the following by 07/08/24 to LPA
  • LIC308- Designation of Administrative Responsibility
  • Liability insurance
  • LIC500- Personnel Report
  • Administrator Certificate

No deficiencies being cited during today's inspection.

Exit interview conducted and report provided
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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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