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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002045
Report Date: 11/28/2023
Date Signed: 11/28/2023 04:58:14 PM


Document Has Been Signed on 11/28/2023 04:58 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Alek Molitvenik, Administrator TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following the receipt of a death report on 11/21/23 for resident (R1). LPA met with caregiver, Icelyn Allen, who contacted Alek Molitvenik, Administrator, by phone.

LPA and the administrator discussed the death report for (R1) which notes that resident ate his lunch and then went outside and suddenly stopped breathing.

The administrator stated that there was no indication or sign that (R1) was not feeling well and about to pass in recent days. The caregiver, who was present when (R1) passed, stated she helped (R1) get in the chair where he collapsed outside. The caregiver immediately called the administrator to inform of what happened.

The administrator agreed to request a copy of the county death certificate from (R1's) family member and provide a copy to the Department upon receipt in the next few weeks.

There are no deficiencies cited in this report.

Exit interview. Copy of report provided.
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)
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