347004505-7-26-2021-27-AS-TTRG-C5ANTN-20210726104502

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347004505
Report Date: 07/26/2021
Date Signed: 07/26/2021 10:45:09 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	ALL CARE, LLC		FACILITY NUMBER:	347004505
ADMINISTRATOR:	RAY GIN		FACILITY TYPE:	740
ADDRESS:	5901 WITT WAY		TELEPHONE:	(916) 714-5170
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	6	CENSUS: 6	DATE:	07/26/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Shiela Seaberg, Assistant Administrator		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced on 07/26/2021 at 9:00 am to conduct an annual inspection visit. LPA was met by Caregiver Mei Chen. LPA was informed by Mei that administrator Ray Gin was not in the facility. LPA spoke with Administrator Ray Gin on the phone and explained the purpose of the visit. Administrator said that his wife, Shiela Seaberg, will arrive at the facility in 25 minutes. Administrator holds current certification #6004232740 and expires on 7/5/2021. Assistant Administrator Shiela Seaberg reported that the certification renewal package has been delivered to certification unit and is currently pending. The facility is licensed for 6 non-ambulatory residents. Approved hospice waiver for 2. There are currently 6 residents. LPA toured the facility with Assistant Administrator Shiela Seaberg on 07/26/2021 at 9:40 am. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, garage, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 114.3 degrees Fahrenheit. LPA observed there to be a sufficient amount of perishable and non-perishable food supply on hand. Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ALL CARE, LLC	FACILITY NUMBER: 347004505
	VISIT DATE: 07/26/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed knives and toxins to be locked away and inaccessible to residents. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA also conducted the infection control domain tool.

The facility mitigation plan was submitted to CCLD, and it was approved on 4/27/2021. Facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

The following forms and documents were requested to be submitted within 15 days:
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) Administrative Organization (LIC309)
(7) Control of Property

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit.

Exit interview conducted and copy of report provided

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3