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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001382
Report Date: 06/27/2023
Date Signed: 06/27/2023 11:04:38 AM


Document Has Been Signed on 06/27/2023 11:04 AM - 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:ROSES AND IVY ELDER CAREFACILITY NUMBER:
045001382
ADMINISTRATOR:PERRY, BRIANFACILITY TYPE:
740
ADDRESS:853 MANZANITA COURTTELEPHONE:
(530) 894-7836
CITY:CHICOSTATE: CAZIP CODE:
95926
CAPACITY:20CENSUS: 15DATE:
06/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Administrator: Cindy DenneyTIME COMPLETED:
11:20 AM
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On 06/27/2023, Licensing Program Analyst (LPA) Ivan Avila, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Administrator, Cindy Denney and explained the purpose of the visit.

LPA Avila and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, backyard, shed, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring and shower chair, paper towels, trash can with lids and 20-second hand-washing poster. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 114 F. LPA observed six (6) fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of three (3) residents' files and three (3) staff files.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 895-5033
LICENSING EVALUATOR NAME: Ivan AvilaTELEPHONE: 530-895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
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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