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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002633
Report Date: 07/16/2024
Date Signed: 07/16/2024 03:17:38 PM


Document Has Been Signed on 07/16/2024 03:17 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:PINE GROVE RESIDENTIAL HOME CARE FOR THE ELDERLYFACILITY NUMBER:
347002633
ADMINISTRATOR:CATUNA. REGHINAFACILITY TYPE:
740
ADDRESS:7213 PINE GROVE WAYTELEPHONE:
(916) 987-1655
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 6DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Reghina Catuna, AdministratorTIME COMPLETED:
03:45 PM
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On July 16, 2024, Licensing Program Analyst (LPA) DeAnna Williams Lyons arrive unannounced to conduct an Annual Inspection. LPA met with Emilia Petcu, Administrator, and informed her the reason for the visit.

LPA and Administrator did not completed the infectious tool questionnaire.

LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. Bathrooms and bedrooms were clean and in good repair. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. Smoke alarms were checked and in good working order. Fire drills are conducted as required. LPA observed an adequate amount of linens and found the first aid kit to be complete. Hot water temperature measures at 113 degrees F.
LPA reviewed 3 resident records and 2 staff records. Resident files were found to be complete and current. A review of staff records indicates that all facility staff have received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates. Facility is conducted staff training as required.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610E the Emergency Disaster Plan, and copy of your current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing no later than August 16, 2024.

Per California Code of Regulations, Title 22, no citations were issued.

A copy of this report was given to Emilia.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
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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