<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002045
Report Date: 11/28/2023
Date Signed: 11/28/2023 04:55:06 PM


Document Has Been Signed on 11/28/2023 04:55 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:COUNTRY OAKS MANORFACILITY NUMBER:
347002045
ADMINISTRATOR:ALEKSANDER MOLITVENIKFACILITY TYPE:
740
ADDRESS:7595 LINDEN AVENUETELEPHONE:
(916) 726-7110
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 4DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Alex Molitvenik, AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with caregiver, Icelyn Allen, and explained purpose of inspection. Alex Molitvenik, Administrator, arrived at approximately 2:35 pm. The facility is licensed for (6) non-ambulatory residents and has an approved hospice waiver for (4) residents. LPA observed all residents to be resting in their rooms at the start of the inspection.

LPA and the Administrator toured the interior and exterior of the facility including the common areas, (5) resident bedrooms, (3) resident bathrooms, kitchen, office, laundry area. LPA observed the facility to be clean, in good repair and odor-free, and the bathrooms to have the necessary grab bars, non-skid flooring, paper towels. Administrator to post 20-second hand-washing poster by each sink. LPA observed sufficient 2+day perishable supply of food, including fresh produce, and 7+day non-perishable supply of food. Sharps, toxins and medications were locked in the kitchen. LPA observed sufficient linens/blankets/incontinent/PPE supplies, PPE, and a complete First Aid kit. The inside temperature was 75*F. Hot water temperature measured 105*F in the kitchen. The fire extinguisher was last serviced 11/6/23. Fire/smoke monoxide alarms are in working order. There are (2) unlocked exits in the backyard and plenty of outdoor/indoor space for activities. Required postings are posted.

LPA reviewed (3) of (4) resident files- they were found to be organized and contain current documentation. Medications were reviewed for (2) residents and no discrepancies were noted. Documentation is maintained and meds are pre-poured only for the day. (1) of (2) staff files were reviewed. Staff has completed all initial training as required, and First Aid/CPR is current for both staff. Administrator certificate #6024306740- exp 1/18/25. Administrator to provide current copy of LIC308, LIC500, liability insurance and LIC9282 (Infection Control Plan) to the Department by 12/8/23.
There are no deficiencies cited.
Exit interview. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1