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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001289
Report Date: 09/07/2024
Date Signed: 09/07/2024 01:44:31 PM


Document Has Been Signed on 09/07/2024 01:44 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:
09/07/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:David Tif, Administrator TIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a health and safety check. LPA met with caregiver, Icolyn "Sonia" Powell who called Administrator Designee, David Tif, who arrived at 12:00 pm. Also present was staff, Jodie Ann Thomas, who was cutting fruit in the kitchen. LPA stated reason for today's inspection. LPA observed (1) resident watching television in the common area at the start of the inspection and (3) residents enter in the common area later during the inspection.

During today's inspection, LPA and caregiver toured the interior of the facility, including both individual resident and common areas. LPA observed the facility to be clean, in good repair and odor-free. There was sufficient 2+day perishable and 7+day non-perishable supply of food on hand. LPA observed (2) unlocked medications in the refrigerator. Both medications belong to resident (R1), who moved in around 8/28/24.

LPA reviewed medications and documentation for (R1). LPA and David Tif contacted Robert Tif, Administrator, to discuss the reason for today's inspection. Also discussed were (3) outstanding Plan of Correction (POC) that were due in August 2024. LPA was advised that staff training has not been completed as of today. Administrator, Robert agreed to complete the required staff training within the next week, or by 9/14/24. LPA clarified the specific training that is required per the deficiencies issued.

LPA and David Tiff also contacted Sam Toplean, spouse of Licensee, by phone, to interview. LPA also briefly spoke to resident (R2).

As a result of today's inspection, (1) deficiency is being cited pursuant to California Code of Regulations, Title 22 Division 6, Chapter 8, on the attached 809-D page.

Exit interview. Copy of report and appeal rights provided to the Administrator Designee.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2024
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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Document Has Been Signed on 09/07/2024 01:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 347001289

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2024
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
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The Administrator Designee immediately secured both medications and stated he would obtain a lock box for the refrigerator following today's inspection.

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Based on observation, the Licensee did not ensure that (2) medications (Valproic Acid 250mg and Deep Relief CBD 50mg/ml), belonging to resident (R1), that need refrigeration were kept in a safe and locked place in the refrigerator, and inaccessible to residents, posing an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2024
LIC809 (FAS) - (06/04)
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