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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004385
Report Date: 11/14/2024
Date Signed: 11/14/2024 11:57:27 AM

Document Has Been Signed on 11/14/2024 11:57 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:LARCHMONT MANORFACILITY NUMBER:
347004385
ADMINISTRATOR/
DIRECTOR:		MARIA YELDONFACILITY TYPE:
735
ADDRESS:7336 LARCHMONT DR.TELEPHONE:
(916) 993-6389
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 6CENSUS: 3DATE:
11/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Maria Yeldon, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 11/14/24 to do case management visit . LPA met with Administrator, Maria Yeldon and explained the purpose of the visit.

Department followed up on SOC 341 and Incident Report (IR) sent by facility on 11/12/24 for regarding resident, R1 where R1 alleged sexual misconduct by staff, S1 while S1 was employed with the facility. Facility notified R1s responsible party, law enforcement and long term care ombudsman (LTCO) and other required agencies regarding this incident.

LPA requested documents related to this incident for R1 and S1 and facility will submit all documents by 11/14/24 by 4pm.

At this time, this case in under review and department will do follow up as needed.
No citations were issued per Title 22 Regulations.
Exit interview conducted and copy of the report left at facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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