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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002577
Report Date: 10/29/2020
Date Signed: 10/29/2020 02:50:06 PM

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:ELDERLY INN IIFACILITY NUMBER:
347002577
ADMINISTRATOR:ROBERT TIFFACILITY TYPE:
740
ADDRESS:5210 ROBERTSON AVENUETELEPHONE:
(916) 972-7003
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
10/29/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Emilia Ardelean, Licensee TIME COMPLETED:
11:00 AM
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A scheduled conference call was held on 10/29/2020 to discuss Licensee's questions regarding surrendering the facility license. Present on the conference call were licensee, Emilia Ardelean, and department personnel: Licensing Regional Manager (RM) Alycia Berryman, Licensing Program Managers (LPMs) Troy Ordonez and Maribeth Senty, and Licensing Program Analyst (LPA) Sabrina Calzada. The following information was discussed:

Regulation 87224 was discussed and how a 60-day written notice, along with a Letter of Intent, are required to be issued to each resident for a change of use of facility, which includes a change in ownership or facility closure. It was clarified that the Letter of Intent, which states the reason(s) for the eviction, can be included in the 60-day written notice issued. Licensee was informed that a copy of the 60-day notice is to be provided to the department within 5 days of issuance.

It was discussed what Licensee's plan is given different possible outcomes with the pending license. Licensee stated she will discuss her plans further with the Administrator and provide the department with a written plan as to how she will proceed in closing her license, given different possible scenarios. Licensee agreed to provide a written plan by end of day, 10/30/20.

Also discussed were resident's and staff's well-being given Covid-19 pandemic, PPE supplies and testing.

LPA stated during the call she would e-mail a copy of the report from today's call to Licensee for her signature. Licensee agreed to return a signed copy to LPA by end of day, 10/29/20.

There are no deficiencies being cited in this report.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
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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