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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004228
Report Date: 09/17/2024
Date Signed: 09/17/2024 12:33:57 PM


Document Has Been Signed on 09/17/2024 12:33 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: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: 4DATE:
09/17/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Administrator, Ioan Nagy TIME COMPLETED:
01:00 PM
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On 09/17/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to conduct a Plan of Correction (POC) case management and met with Administrator, Ioan Nagy .

This POC visit is related to Annual visit conducted on 08/08/24 where citations have been issued and POC requirements were issued for facility. During this visit, LPA cleared Citations issued for CCR Regulations, 87202(a) and 87309(a) from 08/08/24 visit.



On 08/08/24, LPA cited the facility on CCR regulation, 87506(b)- Residents Records- and facility should have submitted all required documents to clear POC by POC Due Date of 08/31/24. Licensee/administrator did not ensure that the POC was corrected upon Due Date of 08/31/24, therefore, on today's date, LPA will be assessing a Civil Penalty of $100/day from 09/01/24- 09/17/24 ,total of $1700.00 for this violation and will continue to accrue until POC is corrected.

On 08/08/24, LPA cited the facility on HSC regulation, 1569.695(c)- Other Provisions- and facility should have submitted all required documents to clear POC by POC Due Date of 09/08/24. Licensee/administrator did not ensure that the POC was corrected upon Due Date of 09/08/24. Administrator stated that facility will conduct fire and disaster drill by 09/17/24 by 5PM and will send proof to LPA upon completion.

LPA informed administrator that Department is inviting administrator for Informal Department Meeting which will be held at 9835 ,Goethe Road #100, Sacramento, CA, 95827 on 10/01/24 at 10:30 AM and attendance is Mandatory to discuss on going issues with facility and administrator stated that they understood and accepted the meeting invite.

Civil Penalties were assessed during this visit for failure to correct the above violation by POC Due Date.


Exit Interview was conducted, Appeal rights were provided, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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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