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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700235
Report Date: 05/20/2024
Date Signed: 06/10/2024 07:29:34 AM


Document Has Been Signed on 06/10/2024 07:29 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/21/2024 08:37 AM

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

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On 5/20/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly health and safety check. LPA Jensen met with Executive Director Carlin Robertson and explained the purpose of today's visit.

LPA Jensen toured the interior of the facility. It was observed to be sanitary and free of odor. The residents were participating in a sing along led by a professional vocalist in the activity room. LPA Jensen tested the delayed egress at 2 exit doors. The doors have a 15 second delay and after pushing down on the door for 15 seconds it opens automatically. They were determined to be fully operational. There is also signage posted at doors with a delayed egress advising of the 15 second delay. As an alternative, the delayed egress doors can be opened immediately with a code. LPA Jensen toured the grounds and observed an outdoor area secured by fence. The outdoor area fence has no delayed egress and opens with a code. The fire clearance allows for delayed egress of not more than 30 seconds and states that the facility meets all requirements and systems have been tested and accepted. On 4/13/24 the facility conducted an in-service training on elopement prevention and response as well dementia behaviors.

LPA Jensen toured the kitchen and observed in excess of a 2 day supply of perishable food and a 7 day supply of non-perishable food. The kitchen was observed to be sanitary and all staff were observed to be following safe food service principals. LPA Jensen toured the medication room. The facility has recently integrated the facilities systems with the pharmacy system through August Health which allows them more efficient access to all resident medication information and flags any possible duplicate orders or errors. The facility is converting to E-MAR effective 5/31/24. LPA Jensen discussed innovations in incontinence care products with Wellness Director and Executive Director.

The facility was observed to be in substantial compliance. No deficiencies were cited during the course of this visit.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
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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