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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001289
Report Date: 09/10/2024
Date Signed: 09/10/2024 01:30:23 PM


Document Has Been Signed on 09/10/2024 01:30 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: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: 4DATE:
09/10/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Robert Tif, Administrator TIME COMPLETED:
01:30 PM
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LPA Sabrina Calzada arrived unannounced to conduct a health and safety inspection. LPA met with Administrator, Robert Tif, who was present. Also present were care staff, Icolyn "Sonia" Powell and Jodie Ann Thomas. LPA observed Bianca Tif, staff, to be assisting Administrator with paperwork. LPA observed (2) residents (R1 and R2) watching television or napping in the common area and resident (R3) in their room. Resident (R4) who is independent was currently out of the facility. There are (4) residents currently.

LPA and Administrator toured the facility and observed the facility to be clean in all areas and cooled to the temperature of 73*F. LPA and Administrator discussed how residents are doing today and the supervision levels needed.

There were no deficiencies observed during today's inspection.

Exit interview. Copy of report provided to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
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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