<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004677
Report Date: 06/11/2021
Date Signed: 06/11/2021 10:53:59 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:CALVINE ELDERLY CARE HOMEFACILITY NUMBER:
347004677
ADMINISTRATOR:NITA, ELENAFACILITY TYPE:
740
ADDRESS:10547 CALVINE RD.TELEPHONE:
(916) 688-9132
CITY:SACRAMENTOSTATE: CAZIP CODE:
95830
CAPACITY:6CENSUS: 6DATE:
06/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Elena NitaTIME 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
On 6/11/21 at 9:30am Licensing Program Analyst (LPA) Kevin Gould arrived at Calvine Elderly Care Home for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Elena Nita and together conducted a tour of the home. The facility is a single story home in a residential area. The facility consists of 8 bedrooms 7 bathrooms, kitchen, dining room, living rooms and a backyard with pool, garden and chickens and tennis court.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed a pool located in the back yard with and enclosed fencing that meets regulations. LPA notes that the pool gate is secure and resident access is restricted. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 106 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes he facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 610E Emergency Disaster Plan, Current Administrator Certificate and Client Roster

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
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 1