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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003892
Report Date: 09/05/2024
Date Signed: 09/05/2024 03:10:48 PM


Document Has Been Signed on 09/05/2024 03:10 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:CARE PROVIDERS AT ARDENFACILITY NUMBER:
347003892
ADMINISTRATOR:APUYA, MARY JANEFACILITY TYPE:
740
ADDRESS:4448 ARDEN WAYTELEPHONE:
(916) 489-1883
CITY:SACRAMENTOSTATE: CAZIP CODE:
95864
CAPACITY:6CENSUS: 4DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Mary Jane ApuyaTIME COMPLETED:
03:21 PM
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On 09/05/2024 at 12:27 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with administrator Mary Jane Apuya. LPA Lee explained the purpose of the visit. Administrator assisted with today’s visit. Administrator certificate # is 6005483740 and will expire on 11/01/2024. The current census is 4 with 2 facility staff.

This facility is a single story building licensed to serve six (6) ambulatory and non-ambulatory residents. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Lee toured the kitchen and observed sufficient seven day non-perishable and two day perishable food supplies. LPA Lee observed knifes made inaccessible to residents in care. Hot water temperature was measured at 105.1 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in dining room and was last serviced on 02/22/2024. The last fire drill was conducted on 06/29/2024. LPA Lee observed the facility has a has a public telephone in the common area. Facility thermostat observed at 77 degrees Fahrenheit. LPA Lee observed toxins located in the laundry and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed Centrally Stored Medication Destruction Record and it was complete. The first aid kit was checked and contained all of the required components.
Continued LIC 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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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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: CARE PROVIDERS AT ARDEN
FACILITY NUMBER: 347003892
VISIT DATE: 09/05/2024
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LPA Lee requested resident and staff files for review. LPA Lee reviewed 4 out of 4 resident files and 3 staff files and they were all complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents were provided to LPA Lee during today’s visit:

(1) LIC 308 Designation of Administrative Responsibility


(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate

The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by 09/09/2024 by 5:00 PM by end of day:

(1) LIC 610D Emergency Disaster Plan


(2) Proof of Current Liability Insurance

As a result of this annual visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted, and a copy of these LIC 809 reports were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC809 (FAS) - (06/04)
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