347001078-7-24-2023-27-AS-TTRG-CU2UVC-20230724155454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347001078
Report Date: 07/24/2023
Date Signed: 07/24/2023 03:55:03 PM

Document Has Been Signed on 07/24/2023 03:55 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	COURTYARD TERRACE		FACILITY NUMBER:	347001078
ADMINISTRATOR:	MAGDA LUIS		FACILITY TYPE:	740
ADDRESS:	3408 ALTA ARDEN EXPRESSWAY		TELEPHONE:	(916) 486-1281
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95825
CAPACITY:	40	CENSUS: 40	DATE:	07/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Magda Luis, Administrator		TIME COMPLETED:	04:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 07/24/2023, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a required annual inspection visit. LPA met with Administrator Magda Luis and explained the purpose of the visit. Administrator holds certification # 6050935740 and has expired on 1/21/2023. Renewal application status is currently pending. The facility is licensed to serve non-ambulatory residents. Hospice waiver approved for (10) residents. There are (39) residents in care currently. LPA toured and inspected the physical plant inside and outside to ensure there were no health and safety concerns. LPA observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room was toured. Medication room was toured. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. Kitchen was toured for adequate food supplies and storage. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed required furniture and lighting throughout the facility. The hot water temperature measured at 118F which was within the required range of 105-120F . The temperature inside the facility was at 75F which was within the required range of 68-85F. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. Proof of current liability insurance was observed. A full Care Tool Inspection was completed at facility. Report continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: COURTYARD TERRACE	FACILITY NUMBER: 347001078
	VISIT DATE: 07/24/2023

NARRATIVE

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LPA requested resident and staff files for review. LPA reviewed (6) resident files and (3) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

The following documents was obtained during today's visit:
LIC 308 Designation of Administrative Responsibility, Administrator Certificate, LIC 500 Personnel Report and Proof of Current Liability Insurance. LIC 610 Emergency Disaster Plan

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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