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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004228
Report Date: 08/29/2023
Date Signed: 08/29/2023 11:19:40 AM


Document Has Been Signed on 08/29/2023 11:19 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:FOUR SEASONS CARE HOMEFACILITY NUMBER:
347004228
ADMINISTRATOR:IOAN NAGYFACILITY TYPE:
740
ADDRESS:8322 CENTRAL AVENUETELEPHONE:
(916) 910-9419
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 3DATE:
08/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ioan Nagy TIME COMPLETED:
11:30 AM
NARRATIVE
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On 08/29/23, Licensing Program Analyst (LPA) Talwinder Bains, conducted unannounced case management visit. LPA met with administrator Ioan Nagy and explained the purpose of today’s visit.

The purpose of this visit is because Administrator on record, Ioan Nagy, Administrators certificate expired on 08/07/2020 (#6019660740). Mr. Nagy did not submit a renewal for their Administrators certificate until today (08/29/23 ) however has not been approved by the Department. A search on the CDSS website for Administrators’ certificates does not reflect Ioan Nagy’s name as ‘pending’ or ‘in process’ status. The Department’s Administrators Certificate Unit indicated that there are several components that still need to be completed for Ioan Nagy to get their administrator certificate. In addition, it has been noted that Mr. Nagy has failed to submit the requested documentation.

Title 22 regulations require any licensed facility to have an administrator with a current administrator's certificate. LPA is issuing a deficiency today due to the facility’s administrator’s certificate being expired. The facility does have a site supervisor, which they are allowed to have as a qualified designated substitute.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.
Failure to correct shall result in civil penalties.

Appeal rights given. Exit interview conducted. A copy of the report has been provided.






SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/29/2023 11:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: FOUR SEASONS CARE HOME
FACILITY NUMBER: 347004228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2023
Section Cited
CCR
87406(g)

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87406(g)- Administrator Certification Requirements. Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements. This requirement is not met as evidence by;
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By 09/28/23, the licensee shall appoint an administrator with a current administrator's certificate until Mr. Nagy’s Administrator certificate is approved. Licensee shall submit newly appointed Administrator and an updated LIC500 and LIC308 to CCL by POC date-09/28/23.
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The administrator certificate for Ioan Nagy expired on 08/07/2020 (#6019660740) and was not put in for renewal till date (08/29/23). This is a potential risk to the health and safety of the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
LIC809 (FAS) - (06/04)
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