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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002577
Report Date: 02/05/2021
Date Signed: 02/05/2021 10:28:10 AM

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: 0DATE:
02/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Robert Tif, Administrator TIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada contacted Robert Tif, Administrator, by phone to issue a citation for a deficiency found during the course of a recent complaint investigation. Findings are being delivered by phone due to current Covid-19 precautionary measures in place. Currently there are no residents at the facility location as there is a pending ownership change.

During the investigation of complaint 27-AS-20200702161524, it was discovered that facility did not maintain records or logs of resident's (R1) home health care visits, when facility emptied the catheter bag or the amount of urine that is emptied from the bag.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is cited on the 809D page. Failure to correct the deficiency by the noted due date may result in a penalty being assessed.

Exit interview. Copy of report and appeal rights e-mailed to Administrator who agrees to return a signed copy of the report to the department by the end of day, 2/5/21.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 347002577
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/19/2021
Section Cited

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87611 General Requirements for Allowable Health Conditions (b) The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following:(1) Documentation from the physician of the following: (B) Medical condition(s) which require incidental medical services: This requirement is not met as evidenced by:
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Based on interview conducted with facility Administrator, the Licensee did not ensure that resident (R1) records were maintained to include home health care visits, when facility staff emptied the catheter bag, or the amount of urine that is emptied from the bag, which posed a potential health and safety risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2021
LIC809 (FAS) - (06/04)
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