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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002721
Report Date: 05/03/2023
Date Signed: 05/03/2023 02:12:47 PM


Document Has Been Signed on 05/03/2023 02:12 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:ADINA HOME CAREFACILITY NUMBER:
347002721
ADMINISTRATOR:LUP, ILEANAFACILITY TYPE:
740
ADDRESS:260 BAURER CIRCLETELEPHONE:
(916) 817-2471
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 0DATE:
05/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Gabriela LepadatTIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Lavinia Muscan arrived on Wednesday May 3, 2023 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed staff files (1). There are no residents currently at the facility. Staff has current first aid and CPR training. Facility was clean and well organized. All required posting were observed. Staff training contained the required initial training.

LPA and Administrator Gabriela Lepadat toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, common areas and outside area. There is no food at the facility as no residents or staff live at the facility and the facility has been non-operational for over 2 years. All exits were unobstructed. The administrator's certificate is current. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use. In the areas toured, there were no health or safety violations observed.

Administrator / Licensee shall contact Community Care Licensing upon admitting a resident.
No deficiencies are being cited as a result of todays inspection.

Exit interview conducted. A copy of this report was printed and given to Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
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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