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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317187
Report Date: 02/07/2024
Date Signed: 02/07/2024 02:09:45 PM

Document Has Been Signed on 02/07/2024 02:09 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:G.M. ROJO GUEST HOMEFACILITY NUMBER:
340317187
ADMINISTRATOR:ROJO, MADELYN M.FACILITY TYPE:
740
ADDRESS:5637 WHITE FIR WAYTELEPHONE:
(916) 344-8072
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY: 6CENSUS: 5DATE:
02/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Madelyn RojoTIME COMPLETED:
02:20 PM
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On 2/7/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit regarding an incident report received on 2/6/24 and met with caregiver. Administrator arrived to assist.

LPA and Administrator reviewed the incident and R1's file.

On 2/6/24, R1 was walking between her room and the restroom when she lost her balance and fell. R1 voiced that her hip hurt but she wished to return to bed and rest. When R1 later attempted to reposition in bed, they again expressed pain. R1's physician was notified. 9-1-1 was called to assess R1. Emergency responders called non-emergency transport. R1 was found to have a hip fracture that does not require surgical correction.

LPA finds that R1 was provided assistance accessing medical care. LPA advised that the Licensee update and train staff on what constitute a medical emergency requiring 9-1-1 be called before all others. The update to policy will be submitted to CCL for the program file.


As a result of today’s inspection, No deficiencies were noted.



Report reviewed. Copy of report and provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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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