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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312701012
Report Date: 04/19/2023
Date Signed: 04/19/2023 03:19:50 PM

Document Has Been Signed on 04/19/2023 03:19 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:OLYMPUS RIDGEFACILITY NUMBER:
312701012
ADMINISTRATOR:KURTZ, DIANAFACILITY TYPE:
740
ADDRESS:248 SKOPAS CTTELEPHONE:
(916) 540-7159
CITY:ROSEVILLESTATE: CAZIP CODE:
95561
CAPACITY: 6CENSUS: 6DATE:
04/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Administartor: Diana Kurtz TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 04/19/2023 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Administrator, Diana Kurtz, and explained the purpose of the visit.

At 2:20 PM, LPA toured the interior and exterior to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, four (4) resident bedrooms, two (2) bathroom, kitchen, and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed food supplies of non-perishables for a minimum of one week and perishable foods for a minimum of two days. Toxic and cleaning supplies locked and is inaccessible to residents in care. The hot water temperature was measured in the kitchen at 109 degrees Fahrenheit. First aid kit was completed. LPA observed fire extinguisher/carbon monoxide alarms to be in working order and the fire extinguisher to be last serviced 06/06/2022. LPA observed the facility's disaster drill records. Fire Drill was last conducted on 03/01/2023.

At 2:40 PM, LPA reviewed a total of three (3) resident files. Residents' files contain signed admission agreements, physician's reports, identification sheets, releases, appraisals, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for three (3) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of two (2) staff records. Staff has training in medications, first aid and CPR, and other various areas of care provision.


No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2023
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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