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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001970
Report Date: 05/05/2023
Date Signed: 05/05/2023 01:01:37 PM


Document Has Been Signed on 05/05/2023 01:01 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:WATERLEAF AT LAND PARK, THEFACILITY NUMBER:
347001970
ADMINISTRATOR:COREEN TIGLEYFACILITY TYPE:
740
ADDRESS:966 43RD AVENUETELEPHONE:
(916) 394-9400
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:78CENSUS: 52DATE:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Coreen TIgleyTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 5/5/23 at 10:30am. Administrator Certificate expires 4/25/24.

LPA met with Coreen Tigley and discussed the purpose of the visit. The facility is licensed for a capacity of 78 Non ambulatory residents. Facility has a hospice waiver for 10 to receive hospice care services. There is 3 resident receiving hospice services at this time. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed and interviewed a random amount of residents who were engaged in activities and others finishing lunch during this visit. LPA observed 2-day perishables and 7-day non-perishables.
The temperature inside the facility was observed to be at 72*F which is within the required range of 68-85*F. The hot water temperature was measured at 119.7*F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.
LPA reviewed 5 resident files and 5 staff files during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308)
Liability Insurance
Administrator Certificate-Updated
Personnel Report (LIC500)

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
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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