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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004307
Report Date: 08/22/2024
Date Signed: 08/22/2024 12:25:13 PM


Document Has Been Signed on 08/22/2024 12:25 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:PINE HOLLOW CARE HOMEFACILITY NUMBER:
347004307
ADMINISTRATOR:MATSKEVICH, TATYANAFACILITY TYPE:
740
ADDRESS:8515 RAPOZO CT.TELEPHONE:
(916) 628-6150
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 3DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator-Tatyana Matskevich TIME COMPLETED:
12:30 PM
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On 08/22/24 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 Tatyana Matskevich 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 residents bedrooms, bathrooms, kitchen, garage, backyard and common areas. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' 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 locked are inaccessible to residents in care. The hot water temperature was measured in the kitchen sink at 118 degrees Fahrenheit, which is within the required range of 105 to 120 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher, which is located in the kitchen, was last serviced on 05/19/2024. LPA observed required Licensing posters posted throughout the facility. LPA reviewed drill logs, which are conducted monthly.

LPA reviewed three (3) resident files, which contains signed admission agreements, physician's reports, identification sheets, consent forms, 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 three (3) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of two (2) staff record. Staff has training in medications, first aid/CPR, and other various areas.

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: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
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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