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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920037
Report Date: 03/20/2024
Date Signed: 03/20/2024 05:14:25 PM

Document Has Been Signed on 03/20/2024 05:14 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:SAPPHIRE SENIOR CAREFACILITY NUMBER:
315920037
ADMINISTRATOR:TULENINOVA, NATALIAFACILITY TYPE:
740
ADDRESS:667 GRIDER DRIVETELEPHONE:
(916) 257-4525
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 6CENSUS: 3DATE:
03/20/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:CaregiverTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 3/20/2024 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home was found to be clean, safe and sanitary. Licensee advised to review sample menu with residents and modify the menu as needed for resident preferences and health needs.

LPA reviewed 3 resident files and 2 staff files. Staff and resident files are incomplete. Licensee advised on required forms an better organization. Licensee advised regarding use of Guardian for transfer requests. Licensee advised regarding valid signed medication orders.

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

Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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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