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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002814
Report Date: 01/09/2025
Date Signed: 01/09/2025 12:23:02 PM

Document Has Been Signed on 01/09/2025 12:23 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FOUR SEASONS HOME CAREFACILITY NUMBER:
347002814
ADMINISTRATOR/
DIRECTOR:		SAVIN, DOINAFACILITY TYPE:
740
ADDRESS:9150 FOUR SEASONS DRIVETELEPHONE:
(916) 682-0398
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Diona SavinTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 1/9/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived to the facility unannounced to conduct an annual required visit. LPA met with Administrator Doina Savin (ADM) and stated the purpose of the visit. Present during this visit are 6 residents with 2 staff on duty.

LPA and ADM toured the facility inside and out to ensure compliance with Title 22 regulations. LPA observed bedrooms, bathrooms, common areas, kitchen area, dinning area, and exterior areas. Facility is a one-story home located in a quiet residential neighborhood. Facility has 5 resident bedrooms. One bedroom is shared. Resident bedrooms were observed to be spacious to accommodate residents' belongings and each bedrooms has an exit to the outside. Two bathrooms were observed and both were equipped with grab bars, commode and slip resistant flooring. Solid waste were properly disposed in close lid garbage cans. Medications, toxins, sharps and other dangerous items were observed to be locked and inaccessible to residents. Carbon monoxide and smoke detectors were observed, tested and found to be operable. Kitchen area was observed to be clean, sanitary and free of clutter.

Fire extinguishers with last serviced on 12/4/24 and was observed to be in working condition. The facility temperature was comfortable at 73*degrees. Hot water temperature in two bathrooms were measured between 118 and 119 degrees F. The facility was observed to have an adequate supply of food to meet the requirements of 2 days of perishable foods and 7 days of non-perishables foods. An emergency supply of food was also observed. Outdoor furniture were observed. Fences and gates on both side of the home were observed to be in good repair. Storage shed at the backyard was observed to be locked. Two window screens were observed to have rip. Advisory was provided to have these window screens to be repaired.

LPA conducted record review of 4 staff files which include, but not limited to, review of 1st Aid/CPR, background clearance, and health screen. No issues were noted at this time.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FOUR SEASONS HOME CARE
FACILITY NUMBER: 347002814
VISIT DATE: 01/09/2025
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LPA conducted 4 resident files which include, but not limited to. review of medical assessments, needs and services plan, centrally stored medication records, and ambulatory status. Medication review of 2 of 6 residents was conducted and found to be in compliance at this time.

LPA also reviewed facility's infection control plan and found to be reviewed annually by the administrator. Facility also conducts quarterly disaster drill. Last drill was conducted on 12/5/24. LPA reviewed first aid kit and found to be in compliance at this time.

LPA requested copy of the following documentation: LIC 500, LIC 308, LIC 610E, current Liability Insurance

Per California Code of Regulations (CCR), Title 22, no deficiencies were observed during today's visit. An exit interview was held, and a copy of the report was provided.


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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
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