502701482-1-10-2025-27-AS-CYAG-DCSLYQ-20250110081042

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701482
Report Date: 01/08/2025
Date Signed: 01/10/2025 08:10:54 AM

Document Has Been Signed on 01/10/2025 08:10 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	ADENA CARE HOME		FACILITY NUMBER:	502701482
ADMINISTRATOR/ DIRECTOR:	OCHOA, ROBERTO		FACILITY TYPE:	735
ADDRESS:	2673 PATTERSON RD		TELEPHONE:	(209) 869-2803
CITY:	RIVERBANK	STATE: CA	ZIP CODE:	95367
CAPACITY: 15		CENSUS: 15	DATE:	01/08/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Roberto Ochoa		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced Prelicensing visit made out to this facility on 01/08/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Roberto Ochoa. A brief interview was conducted with the facility designated Administrator at this time. This facility is seeking licensure and currently undergoing a change in ownership at this time. This facility was not vendorized at this time to accept and retain any regional center clients at this time. Current census was 15 residents. It was learned that there weren't any residents under the care of hospice at this time. It was learned that there weren't any residents diagnosed with dementia at this time. A tour of this facility was conducted. Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Roberto Ochoa. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the certificate expiration date of 09/22/2025 with certificate # 7010682735. Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet and supplies, located in the facility medication room, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator and present staff person at this time. This medication room was observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Linen closets were observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ADENA CARE HOME	FACILITY NUMBER: 502701482
	VISIT DATE: 01/08/2025

NARRATIVE

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Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 06/25/2024 by the local fire extinguisher company, Jorgensen Company, and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.

A review of (5) facility resident records was conducted and noted on the following LIC 858 form.
A review of (5) facility staff records was conducted and noted on the following LIC 859 form.

There were no deficiencies observed or cited during today's annual visit.

This facility was observed to be in compliance at this time.

Exit Interview

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

LIC809 (FAS) - (06/04)

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