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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003884
Report Date: 12/06/2023
Date Signed: 12/06/2023 04:02:27 PM


Document Has Been Signed on 12/06/2023 04:02 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:TAHOE, THEFACILITY NUMBER:
347003884
ADMINISTRATOR:DESCARGAR, BERNADETTEFACILITY TYPE:
740
ADDRESS:8708 SECKEL COURTTELEPHONE:
(916) 686-5715
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
12/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Bernadette DescargarTIME COMPLETED:
04:00 PM
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On 12/6/23 at 3pm, Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced annual required visit, with the use of the CARE Inspection Tool. LPA met with facility administrator, Bernadette Descargar and explained the purpose of today’s visit. The facility is currently licensed to serve 6 non-ambulatory elderly residents. Facility is currently not cleared for bedridden residents, per administrator. The facility is approved for 6 hospice residents. Currently, the facility has 2 hospice residents. Present during this visit, there were 5 residents in care with 3 staff on duty.

At 3:15pm LPA and Administrator inspected the facility’s physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. The facility is a one-story structure located in a residential neighborhood. There were no bodies of water on the premises. Outside of the facility was observed to be cleaned and clear of obstructions. Additionally, LPA observed outdoor furniture for residents’ use and for outdoor activities. Entrance, exits and hallways were observed to be clear of obstructions. LPA observed 5 resident bedrooms and 2 bathrooms for resident use. Facility is also observed to have 1 staff bathroom and 1 staff room. LPA observed beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage for the resident's personal belongings. Bed linens, comforters, and bath towels were adequately stocked during the visit. The resident rooms were inspected. Bathrooms were operational and adequately supplied including with grab bars and non-skid flooring.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were locked and not accessible to residents in care. The kitchen was inspected, and sufficient 2-day perishable and 7-day non-perishable food was maintained adequately. Room temperature was maintained in the facility at 74 degrees F. Water temperature in one of the bathroom was measured at 119 degrees F. Fire extinguisher was serviced on 1/24/23. Smoke detectors and carbon monoxide were tested and found to be operable during this visit. Medication storage area was observed to be locked and inaccessible to residents in care. During this visit, LPA requested an updated copy of LIC 308, LIC 500 and liability insurance.

Due to insufficient time, this annual will require a continuation visit. The Department will return at a later date to complete the annual inspection. An exit interview was held with Bernadette Descargar, Administrator, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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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