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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002045
Report Date: 11/21/2024
Date Signed: 11/21/2024 12:34:54 PM

Document Has Been Signed on 11/21/2024 12:34 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/
DIRECTOR:
ALEKSANDER MOLITVENIKFACILITY TYPE:
740
ADDRESS:7595 LINDEN AVENUETELEPHONE:
(916) 726-7110
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Alex Molitvenik, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Alex Molitvenik, Administrator, and explained the reason for today's inspection. The facility is licensed for (6) non-ambulatory residents and has an approved hospice waiver for (4) residents. LPA observed all (4) residents to be resting in their rooms at the start of the inspection. Currently, there are (0) residents receiving hospice care. During today's inspection, LPA observed a home health nurse visit the care home to meet with one of the residents.

LPA and the Administrator toured the interior/exterior of the facility including common areas, (4) private resident bedrooms, (1) shared resident bedroom, (3) resident bathrooms, kitchen, and laundry area. LPA observed the facility to be clean, in good repair and odor-free. Bathrooms have the necessary grab bars, non-skid flooring, paper towels, and hand-washing posters. There is sufficient 2+day perishable supply of food and 7+day non-perishable supply of food. Sharps, toxins and medications were locked in the kitchen. There are sufficient linens/blankets/incontinent/PPE supplies and a complete First Aid kit. There are (2) unlocked exits in the backyard and sufficient indoor/outdoor space with seating. There are no pools. Additional personal rights to be posted in the common area near the staffing schedule. The fire extinguisher was last serviced 10/18/24 and the smoke/monoxide alarms work. The hot water measured 118*F in the kitchen, and the inside temperature measured 77*F. All exit doors have a signal device.

LPA reviewed (2) of (4) resident and medication files. Records were found to be organized and current. No discrepancies were noted. Facility to request an updated copy of medication orders if there have been changes. (2) of (2) staff files were reviewed. Staff have current First Aid/CPR certifications and are completing required training. RCRE Admin # 6024306740- (exp 1/18/25).

There were no citations issued, but there are (2) Technical Violations being issued.
Exit interview. Copy of report provided to the Administrator.
Maribeth SentyTELEPHONE: (916) 263-4813
Sabrina CalzadaTELEPHONE: (510) 829-2133
DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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