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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001289
Report Date: 09/12/2024
Date Signed: 09/12/2024 12:57:09 PM


Document Has Been Signed on 09/12/2024 12:57 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:
09/12/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Robert Tif, Administrator TIME COMPLETED:
01:00 PM
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LPA Sabrina Calzada arrived unannounced to conduct a health and safety inspection. LPA met with caregiver, Icolyn "Sonia" Powell who called Administrator, Robert Tif, who arrived at 12:20 pm..
LPA observed (2) residents watching television in the common area and observed (1) resident, who is independent, enter the common area. LPA was advised that a second independent resident was currently out of the facility. There are (4) residents currently and (1) resident under hospice care.

LPA discussed that the reason for today's inspection is to provide additional information related to the recent inspections conducted and request a documented staffing plan. LPA and Administrator discussed the details of the letter being requested and that it is due, along with a completed LIC500 (Personnel Report), by tomorrow morning, 9/13/24.

LPA and Administrator toured the interior and observed it to be clean, in good repair and odor free. There is 2+day perishable and 7+day non-perishable supply of food on hand.

LPA discussed resident who is on hospice and updated medication list. Administrator and caregiver advised to document any PRN medication when it is given and to keep daily notes.

Also discussed is that documentation of staff training, per Plan of Correction issued on 7/24/24, is due by 9/14/24 (extended deadline). Administrator, Robert Tif, agreed to also provide (re-send) the Department the required documents, including a letter from the Licensee, to change the Administrator to his name.

Administrator agreed to provide an updated LIC500 and the requested letter by tomorrow morning, 9/13/24, to be emailed to this LPA.

There are no deficiencies issued today.

Exit interview. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024
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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