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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001289
Report Date: 09/08/2024
Date Signed: 09/08/2024 04:10:51 PM


Document Has Been Signed on 09/08/2024 04:10 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:
09/08/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Robert Tif, Administrator TIME COMPLETED:
04:15 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 3:50 pm. Caregiver advised there were (3) residents present at the start of the inspection. LPA observed (2) residents watching television in the common area and (1) resident later enter the common area. There are (4) residents currently.

LPA observed that the (2) medications unlocked in the refrigerator, on 9/7/24, were now secured in a box with a combination lock in the refrigerator. The Plan of Correction issued yesterday was cleared during today's inspection.

LPA toured the facility and observed the facility to be clean in all areas and cooled to the temperature of 73*F.Administrator to place a gate/barrier to the upstairs staff area.

LPA discussed how residents are doing with caregiver and Administrator.

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: 09/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2024
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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