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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001970
Report Date: 06/26/2024
Date Signed: 06/26/2024 03:06:03 PM


Document Has Been Signed on 06/26/2024 03:06 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 51DATE:
06/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Coreen TigleyTIME COMPLETED:
03:30 PM
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On 6/26/24 at 9:00am Licensing Program Analyst (LPA) Kevin Gould and Investigator Tim Balarie arrived at The Waterleaf at Land Park RCFE for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Coreen Tigley and together conducted a tour of the facility.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 115, 126 and 121 degrees F at various locations in the facility, which does not meet the 105-120 degree Fahrenheit regulation. LPA advised facility to turn down hot water in building 2 and advisory note was issued. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA observed facility was still pre pouring medications and advised them of the medications guidance change and provided updated medications guidance from 2021. LPA also observed one resident who is on hospice, does not have an updated LIC 602 (physician's report) LPA requested the facility have hospice complete and updated LIC 602.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report and LIC 9020 client roster.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024
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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