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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001289
Report Date: 09/06/2024
Date Signed: 09/06/2024 04:18:05 PM


Document Has Been Signed on 09/06/2024 04:18 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:
09/06/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Robert Tif, AdministratorTIME COMPLETED:
04:30 PM
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On 09/06/24, Licensing Program Analyst (LPA) Talwinder Bains arrived to conduct a case management and perform a health and safety check on residents in care. LPA met with staff (S1), Icolyn Powell and explained the purpose of todays' visit. S1 called Robert Tif, Administrator who came to facility shortly after and assisted LPA with today's visit.

S1 stated that facility current census is four and they were all male residents . LPA toured the facility with S1 to check the health and safety of residents in care. Areas toured included but not limited to residents rooms, bathrooms, common areas and outside area. LPA toured kitchen area and observed that facility has adequate food supply of 2 days perishable and 7 days non perishable per regulation. LPA observed two residents were in common area and two residents were in their rooms. LPA observed that facility was clean and odor free.

S1 stated that there were 2 caregivers on duty with four residents and there was 1 awake caregiver on night duty on daily basis.


LPA reviewed records for two (2) residents (R1,R2) and two (2) staff files and collected documents during today's visit.

As a result of today’s visit, no deficiencies were cited.
Exit interview was conducted , and a copy was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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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