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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004196
Report Date: 12/05/2023
Date Signed: 12/05/2023 02:08:04 PM


Document Has Been Signed on 12/05/2023 02:08 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:IN LOVING HANDS CARE HOME IIFACILITY NUMBER:
347004196
ADMINISTRATOR:TETYANA HANKEVYCHFACILITY TYPE:
740
ADDRESS:7710 CHIPMUNK WAYTELEPHONE:
(916) 792-7664
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 5DATE:
12/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Tetyana Hankeyvch, Administrator and Adina Sbingu, Administrator Designee TIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Tamara Grant, caregiver and explained purpose of inspection. Administrator Designee, Adina Sbingu, arrived at 11:00 am and Tetyana Hankeyvch, Administrator, and David Sferdian, caregiver/Administrator Designee, arrived at 11:15 am. LPA observed (1) resident sitting at the kitchen table and (4) residents residing in their room. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (2). Currently there are (0) residents on hospice. (2) home health nurses and (1) physical therapist were present also during part of the inspection.

LPA and the Administrator Designee toured the interior/exterior of the facility including the common areas, (6) resident bedrooms, (4) half-bathrooms and (1) main bathroom, kitchen, staff room, garage and locked laundry area. The upstairs area is not used by residents and is gated. LPA observed the facility to be clean, in good repair and odor-free, and the bathrooms to have the necessary grab bars, non-skid flooring, paper towels and hand-washing posters. LPA observed sufficient 2+day perishable/7+day non-perishable supply of food and locked sharps in the kitchen. Toxins are locked in the laundry room and medications are locked in a separate cabinet. LPA observed sufficient linens/blankets/incontinent/PPE supplies, and a complete First Aid kit. The inside temperature was 73*F. Smoke/monoxide alarms are in working order, fire door in compliance, and the fire extinguisher was last serviced 8/1/23. There is a covered patio with seating and (1) unlocked gate on the patio. LPA reviewed (3) resident files and found them to be complete and contain current paperwork. Medications were reviewed for (2) residents and no discrepancies noted. Medication documentation is current and accurate. (3) staff file were reviewed. LPA observed complete paperwork and staff to have recently completed training. All staff is cleared/associated and has current First Aid/CPR certifications. LPA obtained a copy of the current liability insurance and requested LIC500. Discussed current roster. LPA to provide information on Guardian system. LPA confirmed RCFE Administrator certificate was renewed timely per Department website and is processing. There are no deficiencies issued during today's inspection. Exit interview with Administrator. Copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
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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