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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004054
Report Date: 08/13/2024
Date Signed: 08/13/2024 11:52:03 AM


Document Has Been Signed on 08/13/2024 11:52 AM - 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:CALVIN DRIVE CARE HOMEFACILITY NUMBER:
347004054
ADMINISTRATOR:PUHA, MIRCEAFACILITY TYPE:
740
ADDRESS:7221 CALVIN DRTELEPHONE:
(916) 723-1374
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 4DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Administrator- Mircea PuhaTIME COMPLETED:
11:55 PM
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On 08/13/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required 1 year annual inspection utilizing the care tool. LPA met with Administrator Mircea Puha and explained the purpose of the visit.

LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to resident bedrooms, bathrooms, kitchen, laundry room, garage and common areas. In areas toured LPA observed required furniture, and lighting throughout the resident bedrooms and facility. LPA observed resident bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. Knives are locked and inaccessible to residents in care. The hot water temperature was measured in the kitchen at 115.2 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. LPA observed the fire extinguisher located near entrance which was last serviced on 11/03/23. LPA observed required Licensing posters posted throughout the facility.

LPA reviewed four (4) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for two (2) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed two (2) personnel records. Staff has training in medications, first aid, CPR, and other various areas of care provision.

No deficiencies being cited during today's inspection.

Exit interview conducted and report provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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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