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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005578
Report Date: 06/20/2022
Date Signed: 06/20/2022 03:20:31 PM


Document Has Been Signed on 06/20/2022 03:20 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SCANDIA CARE FOR ELDERLY IIFACILITY NUMBER:
347005578
ADMINISTRATOR:HONG NGUYET TRINHFACILITY TYPE:
740
ADDRESS:3920 PLAINSFIELD WAYTELEPHONE:
(916) 515-8482
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 4DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Vincent D. ZepedaTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 06/20/2022 at 1:15 PM. LPA Martinez met with Vincent D. Zepeda and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

The facility is licensed for six non-ambulatory resident. There are currently 4 residents who reside at this facility.

LPA Martinez toured the facility with Vincent D. Zepeda on 06/20/2021 at 1:15 PM.

LPA Martinez observed an sufficient amount of food. The facility is sanitary and fully furnished. The facility bathrooms are furnished. The facility has first aid kit, and medications are made Inaccessible to residents in care. The facility smoke detectors, carbon detectors, and fire extinguisher are in good repair. The facility files are updated. The facility exterior doors are in good repair.

The facility has covid-19 postings throughout the facility. The facility has a 30 day supply of PPE. The facility has submitted a mitigation plan. The facility has one main screening entry. The facility has a designated area for visitors. The facility conducts daily disinfection cleaning.

As a result of this visit, there were no deficiencies cited. An exit interview was conducted, and a copy of the report was provided to the facility at the end of this visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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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