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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700416
Report Date: 11/08/2021
Date Signed: 11/08/2021 03:46:55 PM

Document Has Been Signed on 11/08/2021 03:46 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ELDERLY INN IV, THEFACILITY NUMBER:
342700416
ADMINISTRATOR:TOPLEAN, SAMFACILITY TYPE:
740
ADDRESS:4908 ILLINOIS AVETELEPHONE:
(916) 844-7025
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 6DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Sam Toplean, Administrator TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Anna Richards, caregiver, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA confirmed there are no residents or staff with a confirmed case or signs/symptoms or Covid. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. LPA observed (3) residents to watching television or napping in the common area and (1) resident resting in her shared resident rooms. (1) resident was out of the facility with a family member at time orf inspection. LPA was advised there are no residents on hospice. LPA met with Administrator, Sam, who arrived shortly to the facility.

LPA and caregiver toured the interior of the facility. LPA observed it to be clean and in good repair. LPA observed a few Covid posters throughout. LPA to e-mail additional posters, including one for cough etiquette and proper hand-washing. . Rooms toured include (4) private bedrooms, (1) shared rooms, , (3) bathrooms, kitchen, laundry area and common areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 72* F. LPA observed sufficient 2+day perishable and 7+day non-perishable food. LPA observed paper towels, soap and sanitizer. Administrator to place a trash can with lid and hand-washing poster in the bathrooms. Discussed vaccination status of residents and staff.

Current copy of Administrator certificate to be posted. Fire extinguisher serviced last week- to provide confirmation as service company did not update tag. Discussed staff and visitors wearing masks at all times, even if fully vaccinated. LPA was provided with a copy of completed Mitigation Plan that was provided to the Department on/around January 2021 when due.

There were no deficiencies observed during today's inspection. LPA requested updated copy of liability insurance and LIC308.

Exit interview. Copy of report to be e-mailed to facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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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