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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005115
Report Date: 06/06/2024
Date Signed: 06/06/2024 03:49:54 PM


Document Has Been Signed on 06/06/2024 03:49 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:FAIR OAKS HOME CARE FOR THE ELDERLYFACILITY NUMBER:
347005115
ADMINISTRATOR:LYUDMILA PALAMARCHUKFACILITY TYPE:
740
ADDRESS:8119 OAHU DRIVETELEPHONE:
(916) 962-7458
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
06/06/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Richard Palamarchuk, AdministratorTIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility to conduct a health and safety check and follow-up regarding technical assistance that was provided to the facility during an inspection conducted on 5/01/2024.

During today's inspection, LPA toured the facility. LPA observed facility to be utilizing Centrally Stored Medication Forms for medication administration. LPA observed a two (2) day perishable and seven (7) day nonperishable food supply at the facility.

During inspection, LPA observed knives and disinfectants to be unlocked and accessible to residents in care in the kitchen area. LPA observed that medications were pre-poured for a seven day period.

As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8 regarding hazardous items being accessible to residents and pre-pouring medications.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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 2


Document Has Been Signed on 06/06/2024 03:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: FAIR OAKS HOME CARE FOR THE ELDERLY
FACILITY NUMBER: 347005115

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2024
Section Cited
CCR
87309(a)

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
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Facility locked disinfectants and knives that were accessible to residents during inspection. Facility will ensure that all hazardous items are locked and inaccessible to the residents in care. LPA cleared deficiency at the conclusion of this visit.
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Based on LPA's observations, the facility did not ensure that knives and disinfectants were locked and inaccessible to the residents in care in the kitchen area, which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
06/19/2024
Section Cited
CCR87465(h)(5)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding regulation 87465. Facility will submit statement to LPA by POC due date of 6/19/2024.
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Based on LPA's observations, the facility was pre-pouring residents' medications for a seven-day period, which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
LIC809 (FAS) - (06/04)
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