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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001289
Report Date: 04/19/2022
Date Signed: 04/19/2022 05:04:55 PM


Document Has Been Signed on 04/19/2022 05:04 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:ELDERLY INN I, THEFACILITY NUMBER:
347001289
ADMINISTRATOR:TOPLEAN, DANIELAFACILITY TYPE:
740
ADDRESS:5206 ROBERTSON AVENUETELEPHONE:
(916) 488-4518
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 6DATE:
04/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Joshua Toplean, caregiver TIME COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection. LPA met with Joshua Toplean, caregiver who contacted Administrator, by phone. LPA explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask. Facility currently has (6) residents and (0) residents are on hospice.

LPA and caregiver conducted a brief tour to ensure there were no health and safety hazards or personal rights violations. LPA observed (2) residents to be watching television in the main communal area and (2) residents to be in their rooms and (2) residents out front. Licensee, Sam Toplean, arrived at approximately 4:30 pm.

LPA and Licensee discussed current balance due on annual fees and history of payments. LPA assisted with paying balance in full online. LPA observed confirmation of payment. LPA and Licensee also discussed balance showing on related facility. Licensee to follow up and contact the Department to discuss possible discrepancies in the billing of this facility and related facility. LPA provided contact information for the Department's billing unit.

There are no deficiencies issued today but there is an advisory note issued for a technical violation.

Exit interview. Copy of report to be emailed to Licensee.






SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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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