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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002814
Report Date: 01/06/2023
Date Signed: 01/06/2023 04:13:18 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/06/2023 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
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: 5DATE:
01/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Doina Savin, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst Renee Campbell arrived at the facility on 01/06/2022 at approximately 1:30 pm and explained the purpose of the visit. Doina Savin is the Administrator and holds certificate #6010418740 that expires on 10/20/2023.

This facility is a single story building licensed to serve six (6) ambulatory residents. Three residents may be approved for a hospice waiver. Currently there is a census 5 people in residence. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA Campbell observed sufficient seven-day non-perishable and two day perishable food supplies. Hot water temperature was measured at (116.8) degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 12/07/2022. Thermostat observed at (72) degrees Fahrenheit.

LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA compared medications and MAR for 2 out of 6 residents for the facility. First aid kit was checked and is complete.

No deficiencies were found during today's inspection. Exit interview held with Doina Savin and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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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