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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920180
Report Date: 10/16/2024
Date Signed: 10/16/2024 10:57:01 AM

Document Has Been Signed on 10/16/2024 10:57 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:LONG CREEK HAVEN CARE HOMEFACILITY NUMBER:
315920180
ADMINISTRATOR/
DIRECTOR:
SALVA, LITAFACILITY TYPE:
740
ADDRESS:1415 LONG CREEK WAYTELEPHONE:
(916) 804-2255
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 6CENSUS: 5DATE:
10/16/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Lita Salva, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived to conduct a pre-licensing inspection. LPA met with Licensee/Administrator Lita Salva during today's inspection.

Facility was inspected both indoors and outdoors. LPA inspected 5 resident bedrooms, 2 bathrooms, 1 staff room, common living areas, kitchen, and outdoor areas. Outdoor area is free from hazardous debris. Outdoor exits are clear and accessible. First aid kit was present in the facility. Centrally stored medications are stored in locked staff area near the front door. LPA inspected resident bedrooms and the bedroom had appropriate furnishings, adequate lighting and storage. Bathrooms are clean, sanitary, and in good repair. Grab bars and non-skid mat was present in all bathrooms. Smoke detectors and carbon monoxide detectors were checked. Fire clearance was granted on 07/30/24 for 5 non-ambulatory residents and 1 bedridden resident in room near exit 3. Kitchen is clean, sanitary, and in good repair. A working telephone has be set up for residents use.

Comp III was completed today with licensee.

Licensee needs to fix window screens and a hole in the wall in the staff room. In addition, licensee stated facility sketch needs to be updated to reflect current resident rooms.

LPA will return on a later date to complete pre-licensing inspection.

Exit interview conducted and copy of report provided.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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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