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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700250
Report Date: 05/02/2024
Date Signed: 05/02/2024 02:25:37 PM

Document Has Been Signed on 05/02/2024 02:25 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:OPTIMUM SENIOR CARE HOMEFACILITY NUMBER:
392700250
ADMINISTRATOR/
DIRECTOR:
PRISCILLA QUITEVISFACILITY TYPE:
740
ADDRESS:209 N SCHOOL STREETTELEPHONE:
(209) 339-9846
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 24CENSUS: 22DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:34 PM
MET WITH:Priscilla Quitevis TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 05/02/2024 at 12:30 PM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Priscilla Quitevis and explained the purpose of the visit. LPA Martinez 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.

Administrator certificate expired 10/14/2023, and the Administrator submitted the renewal certification application in a timely manner. The facility is licensed for 24 ambulatory residents, and has a hospice waiver for 6 . There are currently 22 residents who reside at this facility. There are two resident on hospice.

The LPA Martinez toured the facility with Priscilla Quitevis on 05/02/2024 at 2:00 PM.

LPA Martinez reviewed six resident files and six staff files. All files were maintained and complete. LPA Martinez reviewed two medication administration records (MAR), and they were complete and maintained. The facility has a first aid kit, and all medications are stored in a locked medication cart. The facility fire extinguishers are in good repair and inspected in January of 2024. Facility staff will email last fire inspection report to LPA Martinez by 05/06/2024 by 5:00 PM . The facility has an adequate food supply, and the kitchen was sanitary. Resident bedrooms, bathrooms, laundry room, and common living areas were furnished and sanitary. The facility water temperature measured 105 degrees and facility temperature measured at 74 degrees.

Based on this annual inspection, there were no citation. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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