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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002721
Report Date: 05/01/2024
Date Signed: 05/01/2024 04:13:16 PM


Document Has Been Signed on 05/01/2024 04:13 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:ADINA HOME CAREFACILITY NUMBER:
347002721
ADMINISTRATOR:LUP, ILEANAFACILITY TYPE:
740
ADDRESS:260 BAURER CIRCLETELEPHONE:
(916) 817-2471
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 5DATE:
05/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Brandon Lepadat, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 5/1/24 and met with the Administrator, Brandon Lepadat, to conduct a Required-1 Year Inspection.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are five (5) bedrooms and two (2) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 119.1 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguisher and first aid kit are maintained and ready for emergency use.

LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed three (3) resident files and also reviewed two (2) staff files.

As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
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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