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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804186
Report Date: 11/16/2023
Date Signed: 11/16/2023 11:47:35 AM

Document Has Been Signed on 11/16/2023 11:47 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:OCEANSIDE RETIREMENT LIVINGFACILITY NUMBER:
236804186
ADMINISTRATOR:GYURICS, TUNDEFACILITY TYPE:
740
ADDRESS:100 S HAROLD STREETTELEPHONE:
(916) 616-7020
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY: 4CENSUS: 0DATE:
11/16/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Ecaterina KabaiTIME COMPLETED:
12:00 PM
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Licensing Program Analyst Chris Arnhold arrived announced to conduct a Pre-licensing Facility Inspection with applicant. Facility has received fire clearance for four non-ambulatory residents, one of which may be bedridden. Applicant has a received a Hospice Waiver for two residents. Facility has included Dementia Care in the Plan of Operation but will not be advertising for dementia.
Physical Plant: Facility is a single story, three bedroom and 1 bath home. Required postings were not present. Resident's bathroom is located in common hallway. Night light was not present in hallway. Grab bars and nonskid mat were present. Hot water temperature was 122.1F, which is above regulation. There is a secure area for medication storage. There were extra towels, linens and hygiene products for resident use. Kitchen appliances, utensils, and food preparation areas are in good condition. A seven day supply of non-perishable food was present. Stove knobs can be easily removed when stove is not in use. Toxins and cleansers are secured in the laundry area. One fire extinguisher is located in kitchen and another in the living room. All exits have functional auditory alarms. Smoke detectors are operational. Carbon monoxide detector is present. Windows, doors, walls, ceilings, screens, ramps, paint, and furniture are in good condition.
Component III Orientation was conducted at the time of this inspection.
Based on the findings during this inspection the following items require completion:
-Bedroom 1 needs a chest of drawers and a lamp
-Bedroom 3 needs a chest of drawers for each resident and a lamp.
-Hot water temperature to be monitored and stay within regulation
-Night light near the bathroom
-Required postings
Applicant will submit self certification that the requested items have been completed. Upon receipt of self certification, LPA will submit this application for review and approval of license to the Licensing Program Manager.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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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