507002396-9-12-2024-27-AS-RCAL-D932RP-20240912173753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507002396
Report Date: 09/12/2024
Date Signed: 09/12/2024 05:38:06 PM

Document Has Been Signed on 09/12/2024 05:38 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:	SAMARITAN VILLAGE		FACILITY NUMBER:	507002396
ADMINISTRATOR:			FACILITY TYPE:	740
ADDRESS:	7700 FOX ROAD		TELEPHONE:	(209) 883-3000
CITY:	HUGHSON	STATE: CA	ZIP CODE:	95326
CAPACITY:	277	CENSUS: 170	DATE:	09/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Rikki Perezchica, Administrator		TIME COMPLETED:	05:45 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	On 09/12/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannounced to complete an annual inspection. LPA Campbell met with Administrator Rikki Perezchica and explained the purpose of the visit. The facility has a capacity of 277 clients. There is a hospice waiver for up to 15 residents, and a dementia unit that holds up to 30. The main facility consists of administrative offices, the main kitchen and dining room, chapel and residences for Assisted Living clients. There is also a private dining rooms on both the 2nd and 3rd floors. Upon entry, LPA Campbell observed residents participating in a religious service in the facility chapel. Other residents were socializing with each other at the front desk and in passageways. There are currently 170 clients and 130 staff. Of the 170 clients shown in the roster, LPA Campbell selected 8 random names from the client roster to be pulled for review. Of the 140 staff listed on the staff roster, LPA Campbell selected 8 random files to be pulled. Of the files reviewed, none were found to have deficiencies. After consultation with the Administrator, LPA Campbell suggested that LIC 9052 be used to ensure the Employee Rights section of the facility handbook provided to staff is complete. During a tour of the facility, LPA Campbell visited the kitchen, dining room, residents rooms and the emergency food storage room. There was enough food found in the non-perishable pantry room and the emergency food storage room to supply the facility with sustenance for 7 days and enough perishable foods found in the refrigerators to last 3 days. The refrigerators were set at 36 degrees Fahrenheit and the Freezer was 0 degrees Fahrenheit. The floors of the cold storage rooms were clear of debris. On the third floor, another dining room was found. On the door of the dining room, there was a menu for the month of September. Chef Specials were listed daily on the calendar and Weekly Featured Specials were found on the bottom of the menu.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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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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: SAMARITAN VILLAGE	FACILITY NUMBER: 507002396
	VISIT DATE: 09/12/2024

NARRATIVE

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LPA Campbell toured two rooms of the facility and found the necessary furniture and accessories. Each room has its own thermostat and could be set by the resident.. The hot water was in the bathroom of a resident was measured at 115 degrees Fahrenheit which meets the requirement of at least 105 degrees Fahrenheit, and not more than 120 degrees Fahrenheit. In lieu of a smoke alarm test, the administrator provided proof of a yearly Fire System Inspection completeted on 09/27/2023. Fire extinguishers were last inspected on 03/04/2024

LPA Campbell observed an Emergency Response System in use throughout the facilities in clients rooms and in hallways as a signal system. Later while speaking with the Administrator, the sound from the signal system could be heard from a staff members radio. The administrator was cleared to work in the facility and they provided proof that they had submitted their application for renewal of their administrative certificate. The certificate expired 06/23/2024 and the administrator applied for renewal on 05/30/2024. Due to contradictory directions found on form LIC9214 Application for Administration for Certification, no deficiency was cited.

Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted with Rikki Perezchica and a copy of this report was provided.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

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