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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004650
Report Date: 06/21/2024
Date Signed: 06/21/2024 03:58:22 PM

Document Has Been Signed on 06/21/2024 03:58 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:BUENA VISTA HOME IIFACILITY NUMBER:
347004650
ADMINISTRATOR/
DIRECTOR:
ASTRONOMO, REYFACILITY TYPE:
735
ADDRESS:6350 MARIPOSA AVENUETELEPHONE:
(916) 727-7273
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 4CENSUS: 3DATE:
06/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Melody Bulanadi, Co-Administrator/caregiver TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on a recent incident report (SIR) submitted to the Department and on a recent fire inspection. LPA met with Melody Bulanadi, Co-Administrator/caregiver, and explained purpose of inspection. Also present was Edgar Bulanadi, staff. LPA observed (1) client watching television in the common area. (2) clients were resting in their rooms.

LPA discussed the SIR submitted to the Department on 6/7/24 for client (C1) who was sent to the Emergency Room on 6/6/24 following a call staff received from physician that day (4:00 pm) to inform staff that (C1's) lab results were received and showed low hemoglobin levels. Staff immediately sent (C1) to the hospital where her labs were drawn again, confirming her hemoglobin levels were low. (C1) received a blood transfusion of 1 unit, and was admitted to the hospital. (C1) was also given medications for some fluid retention in her lungs. Co-Administrator stated to LPA that (C1) had a scheduled semi-annual appointment, on 5/17/24, with her primary care physician and was treated for edema on her right side, due to possibly leaning to one side for too long, during day program. Melody stated this is the first time lab results show (C1) had low hemoglobin levels. (C1) remains hospitalized at this time, and the facility has been in communication with the local Regional Center regarding new placement since (C1) has increased care needs at this time. LPA discussed issuing a 30-day eviction notice to (C1), if her care needs have increased. LPA printed a copy of Reg 85068.5 during today's inspection.

LPA discussed the recent fire inspection and confirmed that none of the (4) clients have relocated to another resident room. LPA reviewed physician reports, dated 5/15/24 and 5/10/23, for (C2). Both reports note (C2) is ambulatory. Room #5 was re-approved for an ambulatory resident on 6/4/24 by local fire. Rooms #2,3 and 4 are approved for either ambulatory or non-ambulatory. Only (C1) is currently non-ambulatory. LPA and Co-Administrator toured each resident room and confirmed the locks on the staff room(#1) are not locked, per fire clearance, to allow residents in rooms #2/3 to exit through the exit door in room #1, for an emergency. An updated license was printed indicating the approved ambulatory status for each resident room per the fire clearance. There are no deficiencies issued in this report. Copy of report provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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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