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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097002991
Report Date: 04/09/2024
Date Signed: 04/09/2024 02:40:16 PM


Document Has Been Signed on 04/09/2024 02:40 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:NEW WEST HAVEN IIFACILITY NUMBER:
097002991
ADMINISTRATOR:TANIA LANGLANDFACILITY TYPE:
740
ADDRESS:2551 CAMEO LANETELEPHONE:
(530) 677-2979
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:67CENSUS: 31DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Jennifer ScarberryTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPAs) Lavinia Muscan and Talwinder Bains arrived on 4/9/24 to conduct the annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (5) and staff (5) files. All staff files contained the required paperwork and training. Medication review was conducted for (5) residents. Facility is using centrally stored log and MAR record for medication administration, per residents physicians order, without any errors.

LPA and staff toured the facility together to ensure the health and safety of residents in care. The areas toured included, kitchen, hallways, resident apartments, resident dining room/kitchen, and resident common areas. Food is within compliance. Fire drills reviewed. In the areas toured, there were no health or safety violations observed. Fire extinguisher is ready for use.

LPAs requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by end of the month.

No deficiencies cited. Exit interview conducted. A copy of this report was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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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