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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004960
Report Date: 08/26/2021
Date Signed: 08/26/2021 11:54:07 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:EASTERN MANORFACILITY NUMBER:
347004960
ADMINISTRATOR:APUYA, MARIAFACILITY TYPE:
740
ADDRESS:2629 EASTERN AVENUETELEPHONE:
(916) 972-9668
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:13CENSUS: 12DATE:
08/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Geromina BautistaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection on 08/26/2021. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyard of the facility to ensure compliance with Title 22 regulations.

The LPA toured the facility with Geromina Bautista on 08/26/2021 at 11:10 AM.

Administrator holds current certificate and expires on 02/15/2022. The facility is licensed for 13 non-ambulatory residents, and has a hospice waiver for 7 residents. There are currently 12 residents who reside at this facility. There are no residents on hospice.

The facility has submitted a mitigation plan to the Department. The facility has one main entry screening location. The facility has Covid-19 posting throughout the facility. The facility has a 30 day supply of PPE. All visitors, staff, and essential workers are screened for Covid-19 symptoms. The facility conducts hourly disinfection cleaning. Facility common areas are furnished and furniture is spaced 6 feet apart.

The facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time.


Exit interview held and a report given at the end of the visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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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