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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003137
Report Date: 09/03/2024
Date Signed: 09/03/2024 02:48:03 PM


Document Has Been Signed on 09/03/2024 02:48 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:LA FIELD HOME CAREFACILITY NUMBER:
347003137
ADMINISTRATOR:PEREBIKOVSKIY, GALINAFACILITY TYPE:
740
ADDRESS:5729 LA FIELD DRIVETELEPHONE:
(916) 965-7713
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 4DATE:
09/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Galina Perebikovskiy, AdministratorTIME COMPLETED:
03:05 PM
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Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility unannounced on 9/3/24 to conduct a Required-1 Year Inspection utilizing the inspection tool.

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and four (4) bathrooms for resident use. LPAs observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 113.1 degrees F.

LPAs checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPAs observed knives to be locked away and inaccessible to residents. LPAs observed the backyard and perimeter of the care home to be free of clutter and debris. LPAs observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use.

LPAs checked medication storage and found medication to be locked away and inaccessible to the residents. LPAs reviewed four (4) resident files and two (2) staff files. Facility has a current copy of certificate of liability insurance and LPAs requested a copy.

As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. LPAs will return at a later time to conduct interviews with residents and staff and complete annual inspection. Exit interview conducted and copy of report given at the conclusion of this visit.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024
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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