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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002814
Report Date: 01/07/2022
Date Signed: 01/07/2022 11:42:03 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:FOUR SEASONS HOME CAREFACILITY NUMBER:
347002814
ADMINISTRATOR:SAVIN, DOINAFACILITY TYPE:
740
ADDRESS:9150 FOUR SEASONS DRIVETELEPHONE:
(916) 682-0398
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
01/07/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Doina SavinTIME COMPLETED:
11:50 AM
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On 1-7-22 at 9:57am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Doina Savin and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6-bed residential care facility for the elderly with a current census of 6. Facility has 5 bedrooms and a dining area off the kitchen. There is also a formal living room. No obstructions to fire exits. There is a tool shed in the backyard locked and inaccessible to residents in care. LPA also conducted the infection control domain tool.
The facility has an approved COVID Mitigation plan LIC 808 form in place.The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.
Water temperature reads 115.8*F in the bathroom and room temperature reads 74*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. All sharp objects and toxins inaccessible to residents in care.

{Cont. on 809C}
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
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: FOUR SEASONS HOME CARE
FACILITY NUMBER: 347002814
VISIT DATE: 01/07/2022
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Medications were locked and secured. Fire extinguisher was checked 12-7-2021. Facility has an emergency food and water kit. First aid/CPR and COVID vaccination status are current for Staff1 (S1), S2, S3, S4, S5.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with Doina Savin and a report was given to Administrator Doina.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
LIC809 (FAS) - (06/04)
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