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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003747
Report Date: 12/23/2021
Date Signed: 12/23/2021 12:14:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ELDERLY INN II, THEFACILITY NUMBER:
347003747
ADMINISTRATOR:TOPLEAN, SAMFACILITY TYPE:
740
ADDRESS:4824 LIVOTI AVENUETELEPHONE:
(916) 967-1619
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
12/23/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Jennifer Toplean, Co-Administrator TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with caregiver, Valentina Kovalova, who contacted the Administrator, Sam, by phone. LPA met with Jennifer Toplean, Co-Administrator, who arrived to the facility at 11:30 am. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Facility currently has (6) residents and (1) resident is on hospice. LPA observed (1) resident to be watching television in the common area and (5) residents to be resting in their rooms. A second caregiver, Maureen Green, was also present during the inspection.

LPA and caregiver toured the interior of the facility, including (6) private resident rooms, (2) resident bathrooms, kitchen, laundry, caregiver room, and common areas. LPA observed it to be clean and in good repair. LPA observed various Covid posters throughout. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Co-Administrator completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 73* F. Fire extinguisher last serviced 10/29/2021. LPA observed sufficient 2+day perishable and 7+day non-perishable food. LPA observed paper towels, soap, sanitizer and trash cans with lids in the bathrooms. Sharps, toxins and medications are secured appropriately. LPA and Administrator discussed vaccination status of residents and staff as well as visitation protocols per PIN 21-40 issued 8/27/2021. LPA observed signage/information posted at the front entrance that masks are required upon entry.

LPA requested an updated copy of LIC308, LIC500 and current liability insurance be provided to the Department by 12/31/2021. There were no deficiencies observed during today's inspection. Exit interview. Copy of report provided to Co-Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
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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