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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001289
Report Date: 09/18/2024
Date Signed: 09/18/2024 01:42:18 PM


Document Has Been Signed on 09/18/2024 01:42 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) 715-5514
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
09/18/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Robert Tif, AdministratorTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Angela Hood arrived unannounced today, 9/18/24, and met with the Administrator, Robert Tif, to conduct a health and safety inspection.

LPA observed two (2) residents watching television in the common area and one (1) independent resident sitting outside. There are currently four (4) residents in care with 1 of the 4 residents receiving hospice care services. LPA was advised that one of the residents are on an outing today.

LPA discussed that the reason for today's inspection is to request additional documentation and facility plans regarding recent inspections conducted. LPA discussed the details of each item requested.

The requested items are listed below:
  • Behavioral triggers and de-escalations training
  • Environmental modifications
  • Regular care team meetings
  • Enhanced family involvement
  • Proactive medication review
  • Technology integration
  • Personalized activity plan
  • Staffing plan


The facility agrees to provide the Department with the requested information by Friday, 9/20/24.

There are no deficiencies issued today.

Exit interview. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
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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